REPORT 


of 

Investigation  into  the  Operation 


of  the 

British  Health  Insurance  Act 


By 


William  T.  Ramsey 

Chairman  of  the  Health  Insurance 
Commission  of  Pennsylvania 


in  company  with 


Ordway  Tead 

Expert  Investigator 


FOR  THE 

PENNSYLVANIA  HEALTH  INSURANCE  COMMISSION 

OF  1920 


Digitized  by  the  Internet  Archive 
in  2018  with  funding  from 

University  of  Illinois  Urbana-Champaign  Alternates 


https  ://arch  ive.org/detai  Is/reportofi  nvestigOOpen  n_2 


nJLr 


p  c 

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Preface 

T  N  submitting*  this  report,  the  undersigned  desire  to  call  attention 
to  two  facts :  ( 1 )  the  field  inquiry  consumed  only  one  month, 
July,  1920;  (2)  the  method  of  inquiry  was  therefore  necessarily 
confined  to  reading  all  available  documents  and  to  the  interviewing 
of  over  fifty  representative  persons  in  London,  Manchester  and 
elsewhere,  including  government  officials,  employers,  union  officials, 
friendly  society  officers,  commercial  insurance  company  officials, 
insured  workers  and  doctors. 


The  Chairman  of  your  Commission  was  accompanied  to  England 
by  Mr.  Ordway  Tead,  a  professional  consultant  in  labor  problems, 
who  was  retained  to  do  the  specialized  work  involved  in  such  an 
investigation,  and  to  formulate  the  findings.  Since  at  practically 
every  interview  both  of  us  were  present,  not  only  did  we  have 
the  advantage  which  comes  when  two  people  are  seeking  the  facts 
instead  of  one,  but  the  observations  and  conclusions  here  set  forth 
are  those  of  both  the  Chairman  and  the  investigator.  It  was  the 
easier  for  this  agreement  to  be  reached  because  the  outstanding- 
facts  about  the  English  situation  soon  become  apparent  to  any 
honest  and  unbiased  observer. 


The  study  in  England  was  prefaced  by  as  full  a  reading  knowl¬ 
edge  as  possible  of  the  details  of  the  health  insurance  legislation, 
although  this  had  resulted  in  no  settled  conviction  as  to  the  working 
of  the  act.  The  inquiry  was  conducted  with  thoroughly  open  minds, 
without  preconceptions,  with  a  sincere  desire  to  get  the  whole  truth. 

Moreover,  special  pains  were  taken  before  leaving  this  country 


r 

to  communicate  with  prominent  individuals  known  to  be  deeply 
interested  in  health  insurance  either  because  of  their  advocacy  or 
_  their  opposition.  Letters  of  introduction  were  obtained  equally 
j  from  both  groups  and  the  special  effort  throughout  our  visit  was 
<  to  search  out  and  interview  those  in  England  who  were  opposed 
to  the  act.  It  may  be  said  in  passing  that  the  active  opponents  to 
it  are  very  few,  and  many,  if  not  most,  of  the  persons  whom  it  was 
suggested  that  we  see  by  those  on  this  side  of  the  water  known  to 


be  most  critical  of  health  insurance,  turned  out  to  be  in  general 
favorable  to  health  insurance  and  only  critical  of  the  present  act  in 
some  of  its  details. 

In  short,  no  step  was  omitted  that  would  assure  our  hearing 
all  the  adverse  things  that  could  possibly  be  said  by  well-informed 
English  subjects  about  the  working  of  the  act. 

The  result  may  be  unsatisfactory  to  those  who  desire  unqualified 
statements  of  approval  or  disapproval.  For  the  conclusions  reached 
in  this  inquiry  are  not  unqualified.  They  indicate  a  degree  of  suc¬ 
cess  and  a  degree  of  what  is  less  failure  than  confusion  of  purpose, 
which  has  necessarily  resulted  in  gradual  but  important  changes 
in  the  insurance  act  and  in  the  other  public  health  legislation  as 
well. 

This  kind  of  a  qualified  conclusion  will  be  seen  to  be  inevitable 
by  all  who  realize  that  social  institutions  develop  experimentally. 
The  value  of  this  investigation  for  America  is  thus  the  greater 
because  England’s  experiments  need  not  be  repeated  in  every  par¬ 
ticular.  They  can  and  should  be  used  as  the  basis  for  wiser  meas¬ 
ures  designed  specifically  to  meet  American  conditions  and  needs. 

September  15,  1920. 

William  T.  Ramsey, 

Chairman  of  the  Commission. 

Ordway  Tead, 

Expert  Investigator. 


I.  Introduction 


1.  Summarized  Conclusions 


HE  investigation  into  the  operation  of  Health  Insurance  in 


A  Great  Britain  which  was  undertaken  at  the  request  of  your 
Commission,  was  designed  to  find  the  degree  of  success  attending 
the  operation  of  the  present  act,  to  discover  the  attitude  of  the 
various  affected  groups  toward  it,  and  to  consider  as  far  as  possible 
the  extent  to  which  it  might  be  applicable  to  American  conditions. 

It  may  be  said  at  once  that  in  the  main  and  considering  the 
handicaps  and  obstructions  suffered  during  five  years  of  war  the 
act  is  in  reasonably  successful  operation  and  is  beginning  to  produce 
some  of  the  benefits  that  were  initially  urged  in  its  behalf. 

In  the  second  place  the  affected  groups  in  the  community 
are  now  working  the  act  with  a  remarkable  degree  of  co-opera¬ 
tion  and  with  an  all  but  universal  recognition  of  the  value  of 
the  legislation.  Few  in  the  community  would  seriously  advocate  or 
even  contemplate  its  repeal  or  withdrawal.  The  tendency  and 
common  desire  is  in  quite  the  opposite  directions  to  make  the 
act  in  fact  as  well  as  in  name  a  national  act  which  will  really 
assure  good  health  throughout  the  country. 

In  the  third  place,  as  this  report  will  presently  develop,  it  is 
highly  probable  that  much  may  be  learned  from  the  failures  and 
the  shortcomings  of  the  present  operation ;  and  any  rigid  copying 
of  the  British  act  would  certainly  be  quite  unwarranted  when  the 
peculiar  conditions  under  which  it  has  developed  are  understood. 

Points  at  which  the  British  experience  can  most  certainly  provide 
a  useful  warning  are  the  following: 

1.  The  cash  benefits  should  not  be  paid  through  approved  so¬ 
cieties  but  through  local  bodies  publicly  constituted. 

2.  The  cash  benefit  should  be  at  least  50  per  cent  of  wages. 

3.  The  medical  benefits  should  not  be  limited  to  the  insured 
workers,  but  should  extend  to  their  families. 

4.  Hospital  care,  consultant  services  and  specialized  diagnostic 
facilities  in  the  form  of  clinics  and  laboratories  should  not  be  left  out 
of  the  plan,  but  should  be  incorporated  as  part  of  the  medical  benefit. 

This  report  will  amplify  and  explain  the  above  statements.  It 
will  be  exceedingly  difficult  to  offer  anything  like  statistical  proof 


6 


of  them  because  to  a  considerable  extent  that  does  not  exist.  At  j| 
every  turn  and  in  respect  to  every  problem  we  were  repeatedly  told  ] 
“  You  know,  during  the  war  it  was  impossible  to  do  that,  etc.,”  or, 

“  The  experience  of  the  war  years  would  really  vitiate  any  figures | 
we  might  offer.”  Hence,  while  we  have  sought  figures  wherever  1 
possible,  we  have  even  more  sought  the  considered  opinions  of  rep¬ 
resentative  and  typical  spokesmen  of  the  government’s  administra¬ 
tive  staff,  employers,  trade  unions,  approved  societies,  panel  and 
general  doctors  and  insured  workers. 

2.  Purpose  of  the  Act 

It  is  first  necessary  to  consider  what  the  act  was  intended  to  do. 

It  was  advanced  by  Mr.  Lloyd  George  in  1911  to  some  extent  for 
political  reasons,  and  also  to  meet  the  conditions  revealed  in  the 
reports  of  1909  Poor  Law  Commission.  It  was  originally  intended 
to  carry  insurance  against  sickness  and  death  to  workers  and  their 
dependents  through  state  organized  funds.  But  because  of  the 
strength  of  the  commercial  life  insurance  companies  and  of  the 
“  friendly  societies  ”  (working-class  mutual  benefit  societies)  the 
death  feature  was  omitted  and  these  organizations  were  allowed  to 
become  the  agents  for  administering  the  cash  benefits.  And  because 
of  the  work  and  expense  involved  the  dependents  were  excluded 
(except  in  the  case  of  the  maternity  benefit  for  the  wife  of  the 
insured  man). 

The  act  was  designed  to  be  a  preventive  of  ill  health  and  a 
means  of  alleviating  the  destitution  which  it  brought.  If  “  pre¬ 
vention  ”  is  taken  to  mean  discovering  from  the  records  of 
sickness  its  incidence  in  particular  trades  and  local  areas,  with 
special  study  and  treatment  to  reduce  that  incidence  where  it 
is  excessive,  little  has  been  done.  But  if  prevention  means  also 
making  it  easy  for  all  working  people  between  16  and  70  to 
consult  a  doctor  as  soon  as  they  begin  to  feel  ill  or  whenever 
they  are  too  ill  to  go  to  work  and  therefore  want  to  be  certificated 
for  cash  benefits  by  their  doctors  who  must  consequently  ex¬ 
amine  them,  then  the  amount  of  preventive  work  has  been 
tremendous.  Hundreds  of  thousands  of  persons,  it  is  universally 
agreed,  seek  medical  advice  now  who  would  not  have  afforded 
it  before;  and  they  seek  it  promptly.  They  seek  it,  as  the' 
doctors  told  us,  at  a  stage  when  the  length  and  seriousness  of 
the  illness  can  usually  be  reduced.  The  fact  that  there  are 
roughly  twice  as  many  visits  paid  by  doctors  now  as  there  were 


7 


before  the  act  was  in  force  may  be  taken  to  prove  not  that  there  is 
twice  as  much  illness  or  unnecessary  visitation,  but  that  people 
see  the  doctors  as  soon  as  they  feel  indisposed,  and  that  many  people 
now  secure  medical  attention  who  never  got  it  prior  to  the  act.  As 
a  doctor  put  it  to  us,  “If  three  men  come  to  me  two  of  whom  have 
little  or  nothing  the  matter  with  them,  and  the  third  is  in  the  early 
stages  of  some  serious  disease,  all  three  visitations  are  justified.” 

As  to  the  other  purpose  of  the  act,  the  relieving  by  cash  bene¬ 
fits  of  destitution  due  to  sickness  of  the  wage-earner — the  situation 
has  been  so  profoundly  changed  by  the  war  that  accurate  statements 
are  difficult.  The  cash  benefit,  even  as  increased  by  recent  legisla¬ 
tion,  is  so  small  as  compared  with  wages  that  in  cases  of  prolonged 
sickness  the  need  of  some  larger  degree  of  outside  assistance  is  still 
necessary.  The  act  does  not  provide  a  large  enough  cash  benefit  to 
remove  the  possibility  of  destitution  resulting  from  the  wage- 
earner’s  sickness.  Due  to  a  combination  of  causes,  however,  the 
amount  of  actual  destitution  is  less  in  England  (July,  1920)  than 
before  in  recent  years.  It  is,  for  example,  generally  admitted  that 
wages  have  in  most  cases  risen  to  a  degree  that  has  made  provision 
out  of  wages  for  more  food  and  for  illness  more  likely  than  in  pre¬ 
war  days.  Especially  have  the  unskilled  workers  improved  their 
status  in  this  respect. 


II.  Brief  Description  of  the  Act 

THE  original  act  of  1911  was  amended  at  various  points  in 
1913,  1918  and  1920.  Since  the  report  of  the  previous  Health 
Insurance  Commission  of  Pennsylvania1  contains  an  admirable  out¬ 
line  and  summary  of  the  provisions  of  the  basic  legislation,  it  is  only 
necessary  to  mention  below  the  essential  features  of  the  present  law 
and  regulations.  Many  minor  provisions  have  intentionally  been 
omitted  in  the  interest  of  clarifying  the  main  points. 

1.  Contributions 

Men  pay  10  pence  (20  cents)  a  week,  of  which  the  employer 
pays  5  pence  and  the  worker  5  pence.  To  the  amounts  thus  col¬ 
lected  the  state  adds  an  amount  equal  to  2/9  (two-ninths)  of  the 
total. 


1  Report  of  the  Health  Insurance  Commission  of  Pennsylvania,  January, 
1919. 


8 


Women  pay  9  pence  (18  cents)  a  week  of  which  employer  pays 
5  pence  and  the  worker  4  pence.  To  the  amount  thus  collected  the 
state  adds  an  amount  equal  to  %  (one-fourth)  of  it. 

These  contributions  are  payable  in  respect  to  practically  all 
manual  workers,  and  all  non-manual  workers  whose  income  falls 
below  £250  per  year  ($1,250). 

Other  citizens  may  join  as  “  voluntary  contributors,”  but  since 
no  medical  benefits  are  available  for  them  they  pay  a  reduced  con¬ 
tribution. 

The  contributions  are  made  through  the  employer  who  buys 
special  stamps  at  the  post  office.  These  he  is  required  to  affix 
weekly  to  the  card  of  each  employee  as  in  evidence  of  payment. 

If  the  employer  has  more  than  100  employees  he  may  stamp  the 
worker’s  card  half  yearly  with  one  lump  sum,  high-value  stamp 
representing  the  total  amount  of  the  combined  contributions.  These 
cards  are  at  each  six  months’  interval  given  to  the  individual  work¬ 
ers  who  send  them  to  their  respective  “  approved  societies  ”  (pres¬ 
ently  defined)  which  in  turn  use  them  as  evidence  of  payment  to 
get  the  proper  funds  credited  to  them  by  the  Government.  The 
approved  societies  then  distribute  fresh  cards  to  the  employers  with 
whom  their  members  are  at  work. 

2.  Cash  Benefits 

The  man  who  is  certificated  by  the  doctor  as  “  incapable  of 
work”  because  of  some  specific  illness  is  entitled  to  15  shillings 
($3.75)  a  week  after  a  three-day  waiting  period,  which  payment 
may  continue  for  twenty-six  weeks.  And  for  continued  disability 
thereafter  he  gets  7  shillings  6  pence  ($1.88)  a  week  so  long  as  he 
is  incapable  of  work. 

The  benefit  for  a  woman  worker  is  12  shillings  ($3.00)  with 
the  same  disability  benefit  as  the  man’s. 

To  be  eligible  for  these  benefits  the  worker  must  have  paid  con¬ 
tributions  for  26  weeks ;  and  he  is  deemed  to  be  in  arrears  in  his 
contributions  if  they  are  not  made  for  at  least  48  weeks  in  the 
insurance  year.  When  in  arrears  the  worker  is  notified  and  has 
three  months’  grace  in  which  to  become  fully  eligible  by  the  payment 
of  a  fixed  sum  depending) upon  the  length  of  the  arrears  period;  and 
if  that  is  not  paid  he  is  eligible  for  benefits  at  a  lowered  rate. 

A  married  woman  worker  is  entitled  to  40  shillings  ($10)  at 
confinement.  The  wife  of  an  insured  man  is  entitled  in  her  own 
right  to  the  same  amount  when  confined ;  and  if  both  husband  and 
wife  are  working,  two  maternity  benefits  are  paid. 


9 


The  cash  benefits  are  usually  paid  through  the  local  officer  of 
an  approved  society  upon  presentation  to  the  society  of  the  medical 
certificate  from  the  worker’s  doctor  and  also  in  many  cases  after  a 
visit  from  the  society’s  sick  visitor. 

3.  Medical  Benefits 

Every  insured  person  is  entitled  to  medical  attendance  through¬ 
out  his  illness  provided  it  is  service  that  can  be  rendered  by  a  general 
practitioner  of  ordinary  skill  and  capacity.  This  service  does  not, 
however,  include  the  services  of  a  doctor  at  times  of  confinement  of 
an  insured  woman  or  of  the  wife  of  an  insured. 

The  sanitarium  benefit  heretofore  providing  hospital  care  for 
tuberculous  insured  persons,  is  to  be  withdrawn  after  1920  for 
reasons  which  will  be  presently  considered. 

Medical  benefit  also  includes  the  free  provision  of  the  familiar 
drugs  and  medicines  and  of  a  stated  number  of  medical  and  surgical 
appliances  such  as  bandages,  etc. 

There  is  no  statutory  provision  for  hospital  treatment, 
nurses,  dental  treatment,  medical  attendance  upon  the  dependents 
of  the  insured,  specialists’  advice  or  medical  care  at  confinement. 

4.  Administration  of  Cash  Benefits 

There  are  the  following  general  types  of  carrying  funds  which 
the  insured  person  may  join : 

An  approved  commercial  insurance  company. 

An  approved  friendly  society. 

An  approved  trade  union. 

An  approved  establishment  fund. 

In  addition,  there  is  a  class  called  deposit  contributors,  who 
belong  to  no  society,  but  hold  their  own  cards  and  buy  stamps  for 
themselves  at  the  post  office.  Their  contributions  are  only  avail¬ 
able  in  benefits  to  the  amount  of  their  own  and  their  employers’ 
payments;  there  is  no  sharing  of  the  risk  with  the  members  of  any 
group. 

The  worker  has  the  option  of  choosing  his  approved  society;  and 
he  may  not  transfer  except  at  stated  intervals  and  on  payment  of 
two  shillings. 

The  approved  societies  are  not  profit-making  bodies  and  they 
do  not  pool  their  funds.  Each  fund  is  supposed  to  carry  its  own 
burden  of  sickness  and  the  idea  has  been  that  if  any  society  accu¬ 
mulated  a  surplus,  that  value  would  be  available  for  larger  benefits 


10 


to  the  members  of  that  society.  A  valuation  was  to  be  made  every 
five  years  to  determine  the  condition  of  the  funds ;  but  owing  to 
the  war  the  first  valuation  is  only  now  being  brought  to  completion. 
The  results  of  it  will  not  be  published  until  early  in  1921 ;  but  they 
will  probably  show  a  considerable  variation  in  surpluses.2 


5.  Administration  of  Medical  Benefits 

The  local  doctors  who  desire  to  practice  under  the  act — that 
is,  do  the  medical  work  for  the  insured — are  contracted  with  by 
a  local  insurance  committee,  which  is  the  representative  administra¬ 
tive  and  supervisory  body  of  each  local  area  in  respect  to  the 
medical  side  of  the  act.  Doctors  are  now  paid  at  the  rate  of  11 
shillings  per  year  per  person  on  their  “  panel.”  However,  in  Man¬ 
chester  and  Salford,  although  the  total  sum  of  money  available  to 
be  used  in  payment  of  the  local  doctors  is  allotted  at  this  rate,  the 
individual  doctor  is  paid  on  a  visitation  basis  on  a  scale  locally 
agreed  upon. 

Complaints  of  inadequate  or  unsatisfactory  medical  service  are 
supposed  to  be  brought  to  this  insurance  committee;  and  if  there 
is  a  real  case  against  a  doctor  there  is  an  investigation  and  final 
decision  by  a  body  of  inquiry  composed  of  three  doctors  and  a 
barrister. 

Up  until  now  if  there  has  been  doubt  about  the  certification  by 
a  doctor  of  an  insured  person,  the  approved  society  has  usually 
employed  its  own  medical  referee  to  give  an  opinion.  Under  the 
latest  amendment  thirty  state  referees  have  now  been  appointed 
to  look  into  doubtful  cases. 

In  order  to  assure  a  reasonable  division  of  work  and  proper 
service  to  each  individual,  the  size  of  the  panels  is  now  to  be 
limited  to  a  maximum  of  3,000  persons,  with  authority  in  the  local 
insurance  committee  to  restrict  the  number  further  where  they  so 
desire.  In  the  London  area,  for  example,  the  panel  of  any  indi¬ 
vidual  doctor  may  now  be  only  2,000.  In  Manchester,  on  the  other 
hand,  it  may  be  3,000.  As  a  matter  of  fact  the  great  majority  of 
panels  are  less  than  2,000  in  number. 


2  Interim  Report  by  the  Government  Actuary  upon  the  Valuation  of  the 
Assets  and  Liabilities  of  Approved  Societies  as  of  December,  1918. 


11 


6.  Financial  Arrangements 

The  explicitly  recognized  expenses  under  the  act  are  the  follow¬ 
ing: 

1.  The  cash  benefits. 

2.  Payment  to  doctors  at  the  rate  of  11  shillings  per  person  per  year. 

3.  Administration  expenses  of  approved  societies  at  rate  of  4  shillings 
5  pence  per  person  per  year. 

4.  Administrative  expenses  of  insurance  committees. 

5.  Payment  for  drugs  on  basis  of  an  agreed  schedule  of  prices. 

6.  Administrative  expenses  of  Ministry  of  Health  including  indoor  and 
outdoor  staff. 

7.  Reserve  Fund. 

8.  The  contingencies  fund. 

9.  Women’s  Equalization  Fund. 

10.  Central  Fund. 

(The  last  four  funds  are  explained  later.) 

To  meet  these  expenses  there  are  available  the  three-fold  con¬ 
tributions,  and  sundry  parliamentary  grants  which  have  been  called 
for  as  special  problems  have  arisen. 

7.  National  Administration 

The  central  administration  which  includes  allocation  and 
handling  of  accounts,  inspection  of  operation  of  the  act  by  em¬ 
ployers,  insurance  committees  and  approved  societies,  issuance  of 
regulations,  stamps,  cards,  etc.,  is  vested  in  a  department  of  the 
Ministry  of  Health. 

The  actual  arrangements  with  local  doctors  and  the  actual  pay¬ 
ment  of  cash  benefits  is,  however,  left  to  the  several  local  agencies 
above  described. 


III.  Other  Public  Health  Legislation 

NO  adequate  picture  of  the  working  of  the  act  is  possible 
without  mention  of  the  public  health  measures  which  are 
simultaneously  provided. 

In  1919  the  Ministry  of  Health  was  organized  “  for  the  pur¬ 
pose  of  promoting  the  health  of  the  people  ”  of  Great  Britain. 
Under  it  are  now  grouped  for  purposes  of  co-ordination  the 
following  administrative  duties: 

1-  Those  of  Local  Government  Boards  pertaining  to  Public  Health. 

2.  The  administration  of  the  National  Health  Insurance. 


12 


3.  Supervision  of  work  of  Board  of  Education  for  expectant  and  nursing 
mothers  and  of  children  up  to  five. 

4.  Supervision  of  work  of  same  body  in  respect  to  medical  inspection  and 
treatment  of  school  children. 

5.  Supervision  of  midwives. 

Under  other  recent  enactments,  provision  is  already  made  by 
most  local  authorities  with  the  aid  of  special  grants  from  Parlia¬ 
ment  for  treatment  of  tuberculosis,  venereal  diseases,  medical  and 
dental  work  for  school  children,  maternity  and  infant  welfare 
centers. 

The  situation  is  well  summarized  in  the  following  paragraph: 

“  (1)  Before  birth  the  expectant  mother  may  be  dealt  with  by  the  local 
Health  Authority  ( i.e .,  the  Town  or  County  Council,  or  District  Committee), 
under  the  Notification  of  Births  (Extension)  Act  (Child  Welfare). 

“  (2)  At  birth  there  may  be  in  attendance  either  a  midwife  provided  by 
the  Local  Authority  or  a  panel,  or  private  medical  practitioner. 

“  (3)  From  birth  till  five  years  of  age  is  reached,  the  child  again  comes 
under  the  Child  Welfare  Scheme  of  the  Local  Authority. 

“(4)  Between  five  and  fourteen  years,  the  child  comes  under  the  medical 
inspection  scheme  of  the  Education  Authority,  but  if  treatment  is  required 
that  may  be  obtained  from  the  family  doctor  or  through  a  voluntary  or 
charitable  agency,  or  through  clinics  provided  by  the  Education  Authority. 

“(5)  From  fourteen  to  sixteen  years  there  is  no  public  provision  of  any 
kind  for  medical  treatment,  but  the  young  person,  if  seeking  employment  in 
a  factory,  will  be  examined  by  a  certifying  Surgeon  appointed  by  the  Home 
Office. 

“  (6)  From  sixteen  years  of  age  till  the  end  of  life,  the  man  or  woman, 
if  employed,  comes  under  the  Insurance  Acts,  and  receives  Medical  Benefit 
through  the  Insurance  Committee.”  3 

The  doctors  engaged  on  full  or  part  time  under  one  or  another 
of  these  provisions  probably  total  several  thousand,  and  are  thus 
in  fact  the  members  of  an  embryonic  national  medical  service. 

In  addition  to  the  above  provisions  it  should  be  explained  that 
the  Local  Poor  Law  Guardians  also  have  their  own  medical  and 
hospital  provisions  for  destitute  persons  of  any  age.  But  it  is  now 
proposed  and  contemplated  that  all  of  this  work  shall  be  taken  over 
and  done  under  the  local  authorities,  which  will  mean  the  final 
abolition  of  the  Poor  Law  administration  in  so  far  as  it  constitutes 
a  distinct  branch  of  the  medical  service. 

It  is  significant  to  point  out  in  connection  with  all  of  this 
legislation  that  the  tendency  is  definitely  toward  separating 
from  the  insurance  act  all  special  medical  treatment  and  toward 


3  A  Public  Medical  Service,  by  McKail  &  Jones,  1919. 


13 


providing  on  a  universal  public  health  basis  those  medical 
services  which  are  not'  readily  available  through  a  general 
practitioner.  This  is  the  meaning  of  the  removal  of  tuberculosis 
and  venereal  disease  treatment  from  under  the  act;  and  of  the 
institution  of  maternity  centers  and  care  for  all  mothers  under 
an  act  of  1918.  And  it  is  not  unlikely  that  in  the  next  few  months 
the  Government  will  bring  in  a  bill  on  the  hospital  question  which 
will  at  least  provide  state  payment  for  insured  persons  in  hospitals 
and  possibly  for  all  regardless  of  whether  they  are  or  are  not  in¬ 
sured. 

In  short,  the  insurance  act  has  been  one  of  the  potent  in¬ 
fluences  in  rallying  public  attention  and  support  to  a  consistent 
and  complete  program  of  public  health  administration.  And  the 

Ministry  of  Health  will  undoubtedly  in  the  next  few  years  extend 
the  scope  and  improve  the  quality  of  the  medical  services  available 
for  all  the  people.  To  this  extent  the  insurance  act  has  unques¬ 
tionably  been  an  aid  in  the  direction  of  fundamental  preventive 
medicine. 

Having  given  this  brief  sketch  of  the  framework  of  health  in¬ 
surance  legislation  and  administration,  it  is  necessary  next  to  con¬ 
sider  its  actual  operation. 


IV.  The  Act  in  Operation 


1.  Contributions 


T  present  there  is  little  if  any  objection  to  be  found  to  the 


ii.  compulsory  collection  of  contributions,  except  from  those 
who  believe  that  the  contributory  principle  is  less  sound  or  less 
economical  than  the  non-contributory — believe,  namely,  that  cash 
subventions  as  well  as  medical  service  should  be  provided  directly 
out  of  taxes. 

It  appears  to  be  widely  understood  that  in  whatever  way  im¬ 
mediate  expenses  are  met,  it  is  ultimately  industry  itself  from  which 
the  cost  is  met.  Whether  the  contributions  are  direct  by  assessment 
or  indirect  from  taxation,  the  income  out  of  which  payment  comes 
results  from  the  productivity  of  industry  and  agriculture.  And  it 
is  not  generally  felt  to  be  a  matter  of  primary  moment  to  argue 


14 


whether  the  contributions  at  least  for  the  medical  service  should 
be  secured  in  one  way  or  another.4 

On  the  other  hand,  it  is  true  that  the  present  contributory 
method  of  collecting  the  funds  out  of  which  the  cash  benefits 
and  the  medical  benefits  are  paid,  lightens  the  burden  of  direct 
taxation  and  is  not  felt  to  be  an  onerous  burden  by  any  indi¬ 
vidual  employer  or  worker.  From  the  point  of  view  of  adjusting 
the  Government’s  public  health  budget  to  its  available  income 
resources,  this  consideration  becomes,  of  course,  of  almost  de¬ 
termining  importance.  It  should  be  clear,  however,  that  if  we 
in  the  United  States  elect  to  proceed  by  the  contributory  plan  or 
by  public  grants,  there  is  some  substantial  expense  involved. 
Good  health  can  be  bought  only  and  as  soon  as  we  are  willing 
to  pay  the  price. 

As  to  the  administration  for  collecting  the  benefits,  the  work 
and  confusion  are  now  reduced  to  a  minimum.  Yet  it  is  useful  to 
consider  further  (1)  the  method  of  collection  and  (2)  the  cost  of 
collection. 

If  the  contributory  idea  is  to  prevail,  there  must  of  course  be 
some  definite  evidence  of  payment  which  is  readily  available  for 
the  employer,  the  insured,  the  approved  society  and  the  govern¬ 
ment.  The  stamped  card  was  only  adopted  after  the  most  pro¬ 
longed  consideration ;  it  is  admitted  to  be  a  clumsy  method,  but 
no  satisfactory  substitute  has  yet  been  found  which  will  apply  to 
all  cases.  It  is  still  conceivable,  nevertheless,  that  a  simpler  method 
might  be  used  for  all  but  the  most  irregular  and  shifting  types  of 
work  where,  because  the  worker  is  constantly  moving  about,  it  is 
hard  for  him  to  have  at  all  times  evidence  of  his  standing  as  to 
payment. 

The  method  of  lump-sum  stamping  at  the  end  of  each  six 
months  obviates  much  clerical  work.  The  machinery  of  collection 
may  thus  be  said  to  be  running  as  smoothly  as  could  be  expected 
in  a  huge  system  comprehending  15,000,000  people  and  ranging 
from  scrubwomen  who  come  in  by  the  day  to  highly  skilled  artisans 
and  clerks  whose  income  is  regular. 

4  A  valid  criticism  may  be  made,  however,  against  the  restriction  of  the 
benefits  to  a  limited  number.  Sir  Arthur  Newsholme,  Medical  Officer  of  the 
Local  Government  Board,  says,  for  example,  in  a  recent  volume  ( Public 
Health  and  Insurance ,  Johns  Hopkins  Press,  1920)  :  “  On  the  point  of  equity 
it  must  be  admitted  that  any  system  of  so-called  insurance  which,  like  that  of 
the  English  act,  excludes  a  large  proportion  of  the  population  who,  while 
paying  in  taxes  in  aid  of  the  insured,  require  but  do  not  receive  their  benefits, 
is  contrary  to  the  principle  that  any  expenditure  of  Government  funds  should 
ensure  to  the  whole  commmunity  in  need  of  the  provision  in  question.” 


15 


Nevertheless,  thoughtful  administrators  of  the  act,  including 
such  persons  as  approved  society  secretaries,  government  inspectors, 
the  best  doctors,  etc.,  call  the  whole  stamp  machinery  into  question 
— at  least  so  far  as  the  contributions  are  made  to  affect  eligibility 
for  medical  attention.  They  point  to  the  difficulties  created  by 
loss  of  cards  by  workers,  agents  or  approved  societies,  by  failure 
to  stamp  cards,  failure  to  pay  arrears.  They  point  to  the  large 
amount  of  time  and  money  required  to  hunt  down  (1)  the  loss  or 
error  in  one  card,  (2)  to  be  sure  that  employers  are  regularly 
stamping  the  cards,  (3)  to  be  sure  that  workers  are  technically 
eligible  for  benefits  to  which  they  are  entitled  or  which  they  mani¬ 
festly  should  have.  In  the  Government’s  own  inspecting  staff  an 
enormous  amount  of  time  is  certainly  spent  straightening  out  irregu¬ 
larities  in  regard  to  contributions. 

The  cost  of  contributions  and  collection  is  negligible  as  far 
as  the  individual  employer  is  concerned.  The  administrative 
expense  of  bookkeeping  entries  and  stamping  is  surprisingly  small ; 
and  the  employer’s  share  of  the  contributions  is  usually  not  over 
one  per  cent  of  the  payroll.  For  example,  in  one  store  with  over 
7,000  employees  not  more  than  the  equivalent  of  the  full  time  of  two 
clerks  is  devoted  to  the  health  insurance  details.  In  one  factory 
with  about  800  workers  about  half  the  time  of  one  clerk  was  used. 
In  general  this  cost  would  come  to  not  over  one-tenth  of  one  per 
cent  of  the  payroll.  The  testimony  of  employers  was  therefore 
unanimous  that  the  expense  of  the  act  to  them  was  not  a  factor 
of  any  importance. 

From  the  public  point  of  view,  however,  the  total  expense  of 
securing  the  contributions  is  undoubtedly  great  when  all  items  in 
the  account  are  considered — inspection,  printing,  postage,  handling 
of  stamps  and  cards  by  employers,  approved  societies  and  govern¬ 
ment  officers.  And  that  irregularities  regarding  contributions  and 
stamping  should  ever  deprive  the  insured  of  medical  treatment  is 
surely  a  denial  of  the  whole  idea  of  assuring  good  health  among 
the  workers.  It  frequently  happens,  moreover,  that  the  worker 
whose  contributions  are  not  in  good  order,  will  be  the  very  one 
who  needs  most  not  only  the  medical  but  the  cash  benefit  as  well. 

In  short,  the  conditions  determining  the  eligibility  for  cash 
benefits  may  also  disqualify  the  worker  from  benefits  on  the 
medical  side.  This  inter-relation  seems  to  have  little  to  com¬ 
mend  it  from  the  public  health  point  of  view.  There  should,  it 
would  seem,  be  no  question  from  the  public  health  point  of  view 


16 


of  eligibility  for  medical  benefit.  Any  person  needing  medical 
attention  should  be  able  to  have  it. 

2.  Cash  Benefits 

The  cash  benefits,  even  as  now  increased,  is  in  most  cases  such 
a  small  fraction  of  the  possible  wages  that  it  is  decidedly  inadequate 
to  protect  the  income  and  living  standard  of  the  insured  during 
illness.  It  is  generally  conceded  that  the  benefit  should  be  less  than 
wages,  but  a  cash  benefit  which  is  50 c/o  of  wages  is  the  very  least 
that  should  be  considered  if  a  real  subsidy  is  intended.  Yet  with 
a  wage  level  for  men  workers  today  of  between  three  and  a  half 
and  five  pounds  a  week  (from  $17.50  to  $25.00),  the  weekly  cash 
benefit  of  $3.75  is  less  than  25  per  cent  of  wages. 

The  small  size  of  the  present  cash  benefit  not  only  auto¬ 
matically  brings  malingering  to  a  minimum,  but,  as  several 
doctors  said,  the  sick  worker  often  returns  to  work  before  he 
should.  Even  unskilled  workers  are  in  many  cases  able  to  earn 
as  much  in  one  or  two  days'  work  per  week  as  they  could  get  from 
the  whole  week's  benefit.  The  problem  from  the  point  of  view  of 
malingering  only  becomes  difficult  in  cases  of  irregular  work, 
where  the  worker  may  not  have  regular  weekly  employment  and 
thus  may  normally  get  wages  which  do  not  exceed  the  usual  benefit. 

The  promptness  with  which  cash  benefits  are  paid  appears  to 
vary  greatly  with  the  efficiency  of  the  approved  society.  The  best 
organized  societies  unquestionably  pay  claims  promptly  upon  their 
receipt.  Delay  may  be  due  to  many  causes,  principal  among  which 
are  the  question  in  the  mind  of  the  society  as  to  the  validity  of  the 
medical  certification,  and  (in  the  case  of  commercial  companies) 
transfer  of  agents  with  whom  the  insured  thus  gets  out  of  touch 
and  therefore  does  not  know  where  to  submit  his  claim. 

The  cash  maternity  benefit  is  undoubtedly  the  most  popular 
and  the  most  valued.  The  money  is  now  paid  directly  to  the 
woman  beneficiary  and  the  testimony  is  general  that  in  ninety-five 
cases  out  of  a  hundred,  the  money  is  used  to  help  in  defraying  the 
expenses  of  confinement.  It  assures  that  the  mother  takes  care 
to  have  a  qualified  midwife  in  attendance  at  the  confinement.  And 
the  latter  is  sure  to  be  on  hand  since  she  knows  that  the  money  for 
her  fees  is  available.  Moreover,  the  midwife  is  nowf  required  in 
case  of  any  complication  to  call  in  a  doctor  whose  attendance  fees 
are  paid  by  the  local  authorities  under  the  maternity  provisions  legis¬ 
lation  of  1918.  Indeed,  now'  that  there  is  in  most  local  areas  some 


17 


follow-up  work  with  expectant  mothers  (as  a  Public  Health  Pro¬ 
vision),  the  likelihood  is  even  greater  that  the  maternity  benefit  will 
be  wisely  expended. 

The  maternity  benefit  is  not,  however,  adequate  to  cover  all 
the  charges  incident  to  confinement.  The  nurse’s  or  doctor’s  fees 
usually  take  all  or  nearly  all  of  the  benefit,  which  leaves  the  other 
expense  to  be  otherwise  met.  There  is  therefore  a  demand,  espec¬ 
ially  in  labor  circles,  for  the  payment  of  a  larger  amount  which 
will  be  more  in  the  nature  of  a  maternity  endowment  paid  to  all 
mothers. 

There  is  also  on  the  part  of  organized  labor  a  definite  sentiment 
favoring  the  addition  of  a  funeral  benefit  for  the  deceased  worker. 
The  demand  for  this  will  undoubtedly  be  strengthened  by  the  recent 
governmental  inquiry  into  the  operation  of  commercial  insurance 
companies,  which  found  that  in  one  large  company  over  40  per 
cent  of  the  insurance  policies  lapsed  with  consequent  advantage  to 
the  companies  and  no  return  whatsoever  to  the  insured;  and  found 
also  that  “  though  practically  every  person  in  the  wage-earning  class 
is  insured  at  some  point  of  his  life,  at)  least  30  per  cent  of  the  deaths 
among  that  class  are  uninsured  at  death.”5 

Indeed  the  departmental  committee  of  inquiry  intimated  that  “  it 
might  be  practicable  to  propose  a  funeral  benefit  to  be  administered 
under  the  National  Health  Insurance  System.” 

3.  Medical  Benefits 

As  already  suggested,  the  existence  of  free  medical  service  for 
all  insured  persons  means  that  many  now  go  to  doctors  who  did  not 
do  so  before  and  go  at  the  earliest  signs  of  illness.  Everyone  agrees 
that  this  is  an  incalculable  benefit,  the  good  results  of  which  in  a 
better  level  of  health  cannot  fail  to  materialize. 

It  should  be  pointed  out,  however,  that  the  medical  service 
which  is  available  is  neither  thorough  nor  exhaustive ;  nor  is  it 
expected  to  be  under  the  terms  of  the  act.  If  a  doctor  finds 
that  a  case  requires  an  operation,  or  he  is  uncertain  of  the  proper 
diagnosis,  he  must  now  have  recourse  to  hospital  and  consult¬ 
ants  whose  services  are  not  required  to  be  available  to  him  or 
to  the  insured  under  the  act.  It  has  happened  fortunately  up 
until  now  that  the  voluntary  hospitals  (supported  by  private 
subscription  and  by  the  free  work  of  their  medical  staffs)  have 
stood  ready  to  supplement  the  work  of  the  general  practitioner 


6  Industrial  Insurance  Companies  and  Collecting  Societies,  Cd.  614,  1920. 


18 


to  the  extent  of  their  facilities.  In  this  way,  hospital  service  has 
been  usually  available,  although  it  has  never  been  guaranteed, 
never  been  completely  adequate  in  the  urban  districts,  always 
been  dependent  on  private  charity  and  subject  in  no  way  to  any 
control  by  the  patients  or  by  the  public  health  authorities.  It  is 
one  of  the  anomalies  of  the  act  that  its  success  on  the  medical 
side  depends  upon  access  to  hospital  and  consulting  facilities 
which  have  asi  yet  no  organic  relation  to  the  rest  of  the  scheme. 

Now  that  the  hospitals  are  on  the  verge  of  insolvency,  the  Gov¬ 
ernment  is  being  obliged  to  consider  relating  them  to  the  insurance 
provisions  more  formally. 

Much  attention  was  given  in  our  investigation  to  the  quality 
of  medical  service  given.  While  accurate  general  statements 
are  difficult  to  make,  it  is  probably  fair  to  say  that  the  workers 
of  England  are  on  the  whole  now  getting  more  and  better  medical 
service  than  they  ever  did  before  the  act.  It  has  to  be  remem¬ 
bered,  however,  (1)  that  under  the  act  every  registered  general 
practitioner  has  always  been  eligible  to  become  an  insurance 
doctor,  simply  by  making  application;  (2)  during  the  war  a 
great  many  of  the  best  practitioners  were  in  army  or  navy  service ; 
(3)  the  act  only  requires  such  treatment  as  “  can  consistently  with 
the  best  interests  of  the  patient,  be  properly  undertaken  by  a  prac¬ 
titioner  of  ordinary  professional  competence  and  skill. ”  (Medical 
Regulations.) 

These  three  facts  alone  go  far  to  account  for  much  of  the 
criticism  which  has  been  leveled  at  the  quality  of  medical  work 
given  under  the  act.  Moreover,  the  doctors  were  at  first  hostile  to 
or  suspicious  of  the  act.  Today  this  is  not  true.  Out  of  between 
20,000  and  23,000  doctors  (how  many  of  these  are  only  consultants 
and  not  supposed  to  do  insurance  work  is  difficult  to  find  out)  who 
are  in  active  practice,  over  14,000  are  on  the  panels. 

Criticism  of  the  medical  service  has  fastened  on  the  danger  of 
“  lightning  diagnosis on  the  distinction  made  in  attention  given  to 
panel  as  against  non-panel  patients;  on  the  difficulty  of  lodging 
complaint  against  a  doctor ;  and  on  the  fact  that  the  best  doctors  do 
not  become  insurance  practitioners.  There  is  undoubtedly  con¬ 
siderable  basis  for  some  of  these  criticisms  or  they  would  not  be 
repeated  so  often.  But  the  testimony  is  on  the  other  hand  con¬ 
vincing  that  medical  service  is  better  now,  barring  the  handicaps  of 
war  just  noted,  than  it  ever  could  have  been  before  for  thousands 
of  persons.  Now  that  the  number  of  patients  per  insurance  doctor 
is  to  be  limited  and  the  doctors  are  finding  their  panel  practice  in 


19 


most  cases  so  remunerative,  the  reasons  for  inferior  service  will 
be  reduced.  The  doctors  are  and  will  be  increasingly  anxious  to 
keep  the  good  will  of  the  insured  and  of  the  insurance  committee 
as  well. 

The  Scotch  Health  Insurance  Commission  which  until  July, 
1919,  administered  the  act  for  Scotland  says  in  its  latest  report 
that  “  very  little  reliable  evidence  has  emerged  of  neglect  of  duty 
on  the  part  of  insurance  practitioners  or  of  any  real  ground  for 
loose  general  charges  of  inefficiency.  Dissatisfaction  with  a 
limited  service  and  agitation  for  an  extended  and  complete 
medical  and  institutional  service  must  not  be  founded  on  as  a 
condemnation  of  the  present  insurance  scheme  but  rather  as  an 
indication  that  it  has  resulted  in  increased  appreciation  of  the 
importance  of  a  great  development  of  medical  services  in  the 
interests  of  the  national  welfare.”  (Boldface  ours.) 

Invidious  distinction  between  panel  and  non-panel  patients 
is  undoubtedly  still  made ;  but  it  is  generally  considered  to  be 
decreasing.  The  feeling  of  inadequacy  in  the  attention  received 
appears  to  be  a  social  as  much  as  a  medical  matter.  In  those 
cases  where  the  insured  person  does  not  use  his  panel  doctor,  but 
goes  to  another  physician  and  pays  a  private  fee,  the  person  is 
usually  in  the  ranks  of  the  clerical  workers  who  still  feel  a  certain 
class  superiority  to  manual  workers  and  therefore  to  panel  doctors 
who  treat  manual  workers. 

The  real  reason  for  inadequacy  of  treatment  is  affirmed  by 
the  best  doctors  in  England  to  be  due  rather  to  inadequate  medical 
education  and  insufficient  opportunity  for  special  diagnostic  assist¬ 
ance  from  which  insured  and  non-insured  suffer  alike.  Opportun¬ 
ities  for  study  after  the  doctor  leaves  medical  school  are  meager; 
his  opportunities  for  consultation  with  other  practitioners  and 
specialists  are  not  well  organized;  access  to  laboratories  is  not  as¬ 
sured. 

An  offset  to  this  as  well  as  to  other  shortcomings  of  general 
practitioners’  service,  is  increasingly  being  resorted  to  in  the  form 
of  partnerships  of  insurance  doctors.  These  partnerships  are  of 
from  two  to  six  men,  each  of  whom  has  his  assigned  hours  at  the 
offices  and  also  naturally  has  some  diseases  on  which  he  is  more 
of  a  specialist  than  his  colleagues.  Under  this  arrangement  the 
insured  are  certain  of  a  doctor  being  at  hand  all  the  time,  yet  each 
individual  doctor  has  free  time  for  study  and  recreation.  The  terms 
under  which  these  partnerships  work  are  governed  by  regulations 
of  the  Ministry  of  Health,  so  that  the  danger  of  any  abuse  of  the 


20 


plan  is  slight.  Indeed,  such  arrangements  appear  to  be  officially 
encouraged.  Similar  results  are  to  a  certain  extent  obtainable  where 
an  insurance  doctor  hires  an  assistant  to  help  him. 

The  medical  services  under  the  act  are,  it  should  be  emphasized, 
specifically  planned  on  the  theory  that  only  general  practitioners’ 
services  can  at  this  stage  be  given.  Tuberculosis  care,  for  example, 
except  for  domiciliary  treatment,  is  now  removed  from  the  act  and 
entrusted  to  the  local  authorities.  The  insurance  doctor  is  not  sup¬ 
posed  to  have  to  treat  venereal  cases,  which  also  go  to  a  local  clinic. 
Nor  is  the  insurance  doctor  expected  to  take  maternity  cases  unless 
he  so  elects.  But  he  is  supposed  to  be  able  to  diagnose  and  treat 
the  usual  complaints  and  to  act  as  a  clearing  house  for  sending 
special  case&  to  the  necessary  agency.  It  is  in  his  home  contacts  and 
constant  knowledge  of  the  family  that  his  value  lies.  The  policy 
thus  exemplified  seems  to  argue  for  more  adequate  statutory  pro¬ 
visions  to  correlate  general  and  specialist  advice. 

The  question  of  determining  eligibility  for  medical  benefit 
reveals  the  anomaly  of  trying  to  adhere  strictly  to  the  insurance 
principle  in  the  provision  of  medical  treatment  while  at  the 
same  time  trying  to  make  the  physicians’  services  as  fully  available 
to  all  as  possible.  Loss  of  one’s  medical  card,  failure  to  pay  a 
sufficient  number  of  weeks’  contribution  or  failure  to  “  sign  on  ” 
to  a  doctor’s  list,  may  temporarily  make  it  difficult  if  not  im¬ 
possible  for  one  to  be  eligible  for  medical  attention.  Testimony 
is  general,  however,  that  a  person  needing  treatment  is  likely 
to  get  it  regardless  of  his  legal  status  under  the  act.  And  this 
seems  natural.  The  only  real  evidence  which  it  should  be  neces¬ 
sary  to  give  as  to  eligibility  for  treatment  is  increasingly  seen 
to  be  the  need  of  treatment. 

This  principle  does  not  apply  as  yet,  however,  in  the  case  of 
attention  needed  by  the  dependents  of  the  insured.  They  must  pay 
for  their  service;  and,  as  would  be  expected,  the  workers  of  a 
family  go  to  the  doctor  on  the  slightest  provocation,  while  the  non¬ 
insured  persons  will  wait  until  illness  becomes  serious  and  therefore 
doubly  difficult  to  cure.  Yet  even  here  the  tendency  is  for  the 
insurance  doctor  in  his  home  visits  to  consider  the  troubles  of  other 
members  of  the  family  in  which  situation  the  fee,  while  important, 
is  not  the  primary  consideration.  And  without  a  great  deal  of 
bother  the  visiting  insurance  doctor  can  often  direct  a  non-insured 
sick  person  to  the  service  of  local  doctors  available  under  special 
provisions  for  the  tubercular,  for  maternity  cases,  school  children’s 
cases,  etc. 


21 


Decision  as  to  the  eligibility  of  the  insured  for  benefits  in  doubt¬ 
ful  cases  is  now  in  an  unsatisfactory  state,  since  the  standards  of 
different  approved  societies  vary  so  greatly  and  their  method  of 
iocal  follow-up  are  so  different.  As  it  is,  if  the  approved  society 
doubts  the  validity  of  a  claim  it  usually  sends  its  own  doctor  or 
referee  to  see  the  patient,  advising  the  local  doctor  of  the  step  and 
asking  for  his  help.  This  intervention  is  usually  welcomed  and  the 
necessity  for  a  second  diagnosis  is  so  far  recognized  by  all  that 
thirty  referees  are  now  included  as  salaried  doctors  under  the  act. 
Indeed,  it  is  not  inconceivable  that  the  time  may  come  when  there 
will  be  one  doctor  to  give  medical  advice  and  a  wholly  different  one 
to  authorize  the  certification  for  cash  benefits.  It  is  felt  by  many 
that  there  is  much  to  commend  such  a  separation  of  two  quite 
different  functions. 

It  is  in  fact  difficult  to  tell  in  many  cases  whether  incapacity 
for  work  really  exists.  The  border  line  cases  are  many,  especially 
where  there  is  a  tendency  to  diagnose  illness  as  “  general  debility  ” 
and  “  anemia.”  In  such  cases  it  will  be  seen  that  there  are  two 
points  of  view  at  work  and  they  perhaps  form  a  wholesome  cor¬ 
rective  to  each  other.  There  is  the  point  of  view  of  the  approved 
society  anxious  to  suspend  payments  as  soon  as  that  can  be  justi¬ 
fied;  and  there  is  the  point  of  view  of  the  insurance  doctor  who 
usually  sees  the  need,  especially  with  “  run  down  ”  persons,  of  a 
prolonged  rest  without  worry  and  under  wholesome  conditions.  It 
is  admittedly  hard  to  reconcile  these  points  of  view  where  the  sur¬ 
rounding  conditions,  economic  and  otherwise,  are  constantly  work¬ 
ing  to  negative  the  efforts  of  the  doctor.  Truly  preventive  work 
in  many  cases  requires  more  than  cash  or  medical  benefits.  It 
requires  more  food  and  better-cooked  food,  more  fresh  air,  more 
quiet,  no  worry,  etc.  Failing  these,  cash  benefits  and  bottles  of 
medicine  or  tonic  may  be  poured  out  unceasingly  without  apprecia¬ 
ble  results. 

It  should  be  noted,  in  short,  that  under  any  act  it  will  be  difficult 
in  certain  cases  to  define  when  the  person  is  sick;  and  it  will  be 
necessary  while  giving  medical  service  without  stint  to  use  care 
in  paying  cash  benefits  for  these  border-line  instances  of  incapacity 
or  valetudinarianism. 

This  is,  of  course,  an  aspect  of  the  problems  of  malingering. 
There  is  undoubtedly  some  of  this  kind  of  unconscious  malinger¬ 
ing  which  has  to  be  guarded  against ;  and  the  use  of  referees 
under  the  act  is  essential  to  keep  this  at  a  minimum.  It  is  also 
necessary  to  this  end  to  have  the  administration  of  cash  benefits 


22 


in  the  hands  of  a  local  agency  which  can  really  be  in  intimate 
touch  with  the  beneficiaries. 

At  present  there  is  the  further  safeguard  of  weekly  certification 
for  cash  benefits  by  the  doctors  (except  in  chronic  cases  where  the 
approved  society  agrees  to  accept  a  bi-weekly  or  monthly  certifica¬ 
tion). 

Apart  from  these  comparatively  exceptional  border-line  cases, 
the  amount  of  deliberate  malingering  is  agreed  by  all  to  be 
negligible.  Indeed,  as  a  problem  of  practical  administration,  it  has 
hardly  to  be  reckoned  with. 

4.  Extension  of  Medical  Benefits 

The  Government  health  insurance  budget  of  1914  contained 
estimates  for  the  services  under  the  act  of  referees,  consultants 
and  nurses.  It  is  therefore  fair  to  say  that,  although  the  war 
prevented  the  addition  of  any  of  these  services,  they  were  con¬ 
templated  as  parts  of  an  adequate  plan.  It  is  probable  that  within 
the  next  year  the  Government  will  again  introduce  plans  to  aid 
in  the  provision  of  hospital  beds,  consultants’  services  and  perhaps 
nurses5  services.  Already  one  of  the  approved  societies  with  a 
membership  of  over  300,000  gives  dental  treatment  free  to  the 
insured. 

There  is  considerable  demand  in  labor  circles  for  the  extension 
of  medical  benefits  to  the  families  of  the  insured.  It  is  recognized 
that  this  would  entail  a  larger  contribution,  but  it  would  be  pro¬ 
portionately  less  than  the  amount  necessary  to  protect  the  men 
alone. 

This  demand  reaches  its  logical  culmination  in  the  stand  of  the 
Labor  Party  for  a  national  medical  service  under  which  medical 
attendance  would  be  available — much  as  education  now  is — for 
anyone  who  wanted  it.  The  distinction  should  be  noted,  however, 
between  a  “  state  medical  service  ”  and  a  “  national  medical  service.” 
Under  the  former  all  doctors  would  be  full  time  salaried  servants 
of  the  state.  The  advocates  of  such  a  plan  are  naturally  few. 
Under  the  latter  the  state  would  rather  aim  to  build  up  and  provide 
such  medical  service  as  was  needed  to  assure  the  public  health; 
leaving  to  private,  individual  and  voluntary  attention  the  doctors 
and  patients  who  did  not  choose  to  receive  the  benefits  of  the  public 
service,  just  as  now  public  education  is  available  for  all  unless  the 
individual  chooses  to  substitute  a  competent  private  school. 


23 


The  Association  of  Approved  Societies,  including  some  of  the 
largest  friendly  society  and  trade  union  approved  societies  to 
which  belong  some  six  million  insured,  has  also  recently  come 
out  for  nationalizing  the  medical  service  in  the  sense  used  above 
as  the  most  satisfactory  way  of  getting  medical  attention  for  all 
with  as  little  red  tape  as  possible. 

The  doctors  as  represented  by  the  British  Medical  Association 
are  opposed  to  the  idea  of  a  national  medical  service,  although 
they  recognize  and  approve  the  tendency  of  the  state  to  provide 
certain  consulting  and  specialist  services  in  the  hospitals  on  a  salary 
basis  as  well  as  for  the  local  authorities  to  make  the  medical  provi¬ 
sions  which  they  do.8 

It  is,  indeed,  a  fact  which  no  one  in  England  ignores  that  wholly 
apart  from  the  insurance,  there  are  today  several  thousand  whole 
or  part  time  doctors  in  the  salaried  employ  of  one  or  another  gov¬ 
ernmental  body;  and  the  number  is  constantly  increasing.  If  the 
insurance  doctors  are  included  in  this  number  it  would  total  close 
to  18,000  doctors.* 1 2 3 4 * * 7  When  applications  were  sought  for  the  thirty 
referees  posts  to  be  filled  this  summer  there  were  over  1,300  ap¬ 
plicants;  which  certainly  indicates  no  great  reluctance  on  the  part 
of  doctors  to  accept  a  salaried  position  with  the  government. 


6  The  following  quotation  from  an  article  on  “  The  Future  of  the  Medical 
Profession  ”  in  the  British  Medical  Journal  for  October  19,  1918,  indicates 
quite  typically  a  prevailing  view  among  many  thinking  doctors  as  to  the  types 
of  medical  service  which  they  would  like  to  see  available : 

“What,  then,  should  be  the  profession’s  constructive  policy?  In  formu¬ 
lating  this  it  were  well  shortly  to  consider  the  basis,  or  bases,  on  which  the 
profession  renders  service  to  the  community  at  present,  and  these  services 
can  be  classified  under  four  heads,  according  as  they  are  rendered,  under  con¬ 
ditions  of : 

1.  Salaried  service,  whole  time  or  part  time — for  example,  public  health 
appointments,  tuberculosis  appointments,  school  medical  appointments,  etc. 
(military  medical  services  are  not  under  consideration).  These  are  conditions 
of  “  State  Medical  Service.” 

2.  Part  time  contract  service — for  example,  national  health  insurance 
work. 

3.  Voluntary  service — for  example,  work  done  at  charitable  hospitals. 

4.  Individual  service — for  example,  private  practice.  This  can  be  divided 
into  two  heads,  according  as  it  deals  with  (a)  general  work,  (b)  consultant 
and  specialist  work.” 

7  “  The  majority  of  the  medical  profession  in  Great  Britain  is  engaged  in 
either  whole-time  or  part-time  service  for  the  state  or  for  local  authorities. 
Of  the  24,000  medical  practitioners  in  England  and  Wales,  some  5,000  are 
engaged  as  poor-law  doctors,  some  4,000  or  5,000  in  the  public  health  service, 
possibly  500  in  the  lunacy  service,  some  1,300  in  the  school  medical  service, 
and  smaller  numbers  in  various  other  forms  of  medical  service  for  the  state. 
This  is  exclusive  of  the  general  practitioners  who  undertake  contract  work 
under  the  National  Insurance  Act,  and  who  cannot  fall  far  short  of  three- 

fourths  of  the  total  membership  of  the  profession.  It  should  be  noted  that 
many  doctors  held  several  appointments.” — Public  Health  and  Insurance,  by 

Sir  Arthur  Newsholme,  page  83. 


/ 


24 


There  is  also  an  association  of  about  500  doctors  actively  in 
favor  of  a  national  medical  service. 

These  facts  are  dwelt  upon  at  length  because  this  particular 
problem  is  significant  for  America  as  illustrating  how  a  situation 
was  not  fully  faced  at  the  outset.  Whether  Great  Britain  was 
to  have  an  insurance  plan  for  dealing  with  health  or  a  public 
health  program  supplemented  by  cash  benefits,  does  not  appear 
to  have  been  candidly  considered  by  the  initiators  of  the  legisla¬ 
tion.  As  a  result,  the  experiments  have  conclusively  shown  the 
need  for  making  whatever  medical  provisions  are  offered  uni¬ 
versally  available  without  regard  to  the  industrial  status  of  the 
citizen,  his  income  limit,  or  his  standing  in  a  scheme  of  cash 
subventions. 

In  solving  this  problem  serious  consideration  has  to  be  given 
to  the  attitude  of  the  medical  profession  itself.  Its  co-operation 
is  manifestly  essential  to  any  plan  the  community  decides  to 
undertake.  But  that  co-operation  can  so  easily  extend  over  into 
dictation  that  the  experience  of  England  is  a  useful  warning. 
The  outstanding  features  of  any  plan  to  be  adopted  should  be 
offered  to  the  medical  profession  for  an  opinion  and  for  sug¬ 
gestion  as  to  ways  and  means.  But  it  will  be  a  serious  mistake 
to  allow  those  who  are  accustomed  to  think  that  they  “  have  a 
vested  interest  in  ill  health,”  to  dictate  how  much  or  how  little 
medical  service  the  community  shall  provide  for  itself  on  a  public 
and  universal  basis.  On  that  matter  of  fundamental  policy  which 
is  really  the  first  problem  to  be  faced  in  working  out  a  plan  for 
health  insurance  or  other  public  health  provisions,  the  doctors’ 
advice  should  not  be  final,  as  they  are  likely  to  have  a  too 
ex  parte  view.  It  is  true  of  the  doctor’s  relation  to  the  state, 
as  of  the  relation  of  other  professional  experts,  that  when  basic 
policies  are  being  determined  “  the  expert  should  be  on  tap 
but  not  on  top.” 

Contrary  to  the  usual  impression  in  America,  however,  the 
doctors  are  not  today  opposed  to  the  British  act.  Quite  the 
opposite  is  the  fact.  They  realize  and  state  freely  that  “  the 
doctors  are  better  off  under  the  act  than  they  were  before.  They 
have  an  assured  regular  income  and  no  bother  with  collections.” 
As  one  doctor  in  a  peculiarly  influential  position  said :  “  The 
doctors  could  not  be  pried  loose  from  the  act  with  a  crowbar.” 
Such  remarks  should  not  be  taken  to  mean  that  doctors  feel  that 
they  have  a  sinecure  under  the  act.  But  it  has  brought  a  degree 
of  economic  independence  in  the  profession,  which  is  unprece- 


25 


dented,  and  has  served  as  a  spur  to  better  workmanship  and  to 
the  enlistment  in  the  profession  of  more  young  men  and  women 
than  the  medical  schools  have  ever  before  had.  The  fact  that 
the  doctors  have  a  small  organization  which  is  actually  a  trade 
union,  and  another  large  and  powerful  body  which  is  to  all 
intents  and  purposes  a  professional  union,  and  that  both  of  these 
organizations  represent  the  doctors  in  collective  bargaining  with 
the  government,  should  not  lead  to  the  conclusion  that  there 
is  an  absence  of  co-operation  in  these  official  relations.  This 
fact  does,  however,  point  strikingly  to  the  importance  of  having 
groups  of  officials  both  in  the  actual  governmental  administra¬ 
tion  and  in  the  local  areas  strong  enough  to  carry  on  the  inevita¬ 
ble  bargaining  process  in  a  way  calculated  to  assure  that  the 
rights  of  the  tax  payer  (that  is,  everyone)  and  of  the  patient  are 
protected. 

In  saying  that  the  doctors  are  today  favorable  to  the  act  we  do 
not,  however,  ignore  the  opposition  which  exists  especially  to  cer¬ 
tain  details  of  the  present  administration.  The  greater  part  of  the 
practitioner’s  contact  with  the  Government  comes  through  his  rela¬ 
tions  with  the  local  insurance  committee  (upon  which  the  doctors 
have  of  course  at  least  three  representatives).  And  it  is  inevitably 
true  that  varying  standards  and  regulations  should  be  set  by  these 
committees.  This  may  give  rise  to  legitimate  annoyance  as  may 
also  the  regulations  which  may  be  imposed  from  the  office  of  the 
central  administration  in  the  Ministry  of  Health.  But  it  would  be 
wrong  to  think  that  such  regulations  are  imposed  without  oppor¬ 
tunity  for  conference.  There  is  a  National  Advisory  Committee 
upon  which  the  doctors  are  represented  which  considers  just  such 
matters  as  these  . 

Moreover,  when  all  is  said,  two  facts  have  to  be  remembered : 
Some  degree  of  oversight  of  the  work  of  the  individual  doctor 
is  surely  in  the  public  interest;  it  is  only  important  to  be  sure 
that  it  is  an  oversight  exercised  reasonably  and  tactfully.  And, 
secondly,  the  English  doctor  does  not  have  to  become  an  in¬ 
surance  doctor  unless  he  so  elects.  And  even  when  he  does,  his 
private  practice  is  still  open  to  him  to  any  extent  which  his  strength 
enables  him  to  carry  it.  His  panel  practice,  however,  need  be  as 
large  and  no  larger  than  he  desires,  since  he  does  not  have  to  take 
an  insured  person  upon  his  list  unless  he  wishes  to.  Over  14,000 
doctors  did  not  willingly  “  subjugate  themselves  to  the  state  ”  or  to 
the  insurance  patients,  nor  would  they  if  the  relationship  was  irk¬ 
some,  continue  so  to  do  for  eight  years.  The  fact  is  that  once  the 


I 


26 


arrangement  was  entered  into  the  doctors  did  not  on  the  whole  find 
it  onerous,  unduly  inquisitorial  or  destructive  of  their  freedom.  As 
pointed  out  in  the  footnote  on  page  23,  they  recognize  the  need  for 
a  variety  of  types  of  medical  service,  all  of  which  should  be  avail¬ 
able  both  to  the  public  and  to  the  individual  doctor  who  is  choosing 
a  congenial  type  of  professional  activity. 

Medical  opposition  to  the  health  insurance  idea  in  our  own 
country  fastens  to  some  extent  on  the  idea  that  the  “  contract  ”  with 
the  Government  involves  an  ignominious,  subordinate  and  undignified 
relationship  of  the  doctor  to  the  rest  of  the  community.  Nothing  is 
further  from  the  truth  if  the  British  experience  can  be  taken  as 
proof.  It  is,  of  course,  true  that  when  this  contractual  relation¬ 
ship  is  established  many  points  have  to  be  made  explicit  which  as 
between  the  doctor  and  the  private  patient  have  been  largely  implicit. 
But  to  this  no  conscientious  physician  can  have  or  in  England  does 
have  objection.  For  example,  the  contract  requires  that  the  physi¬ 
cian’s  services  shall  be  available  under  the  following  terms : 

“  A  practitioner  is  required  to  attend  and  treat  at  the  places,  on  the 
days  and  at  the  hours  to  be  arranged  to  the  satisfaction  of  the  Committee, 
any  patient  who  attends  there  for  that  purpose,  but  he  may  with  the  consent 
of  the  Committee,  which  shall  not  be  unreasonably  withheld,  alter  the  places, 
days,  or  hours  of  his  attendance,  or  any  of  them,  and  shall  in  that  event 
take  such  steps  as  the  Committee  considers  necessary  to  bring  the  alteration 
to  the  notice  of  his  patients.”s 

In  this  as  in  its  other  provisions  it  is  fair  to  say  that  the 
contract  is  only  laying  down  for  all  practitioners  a  standard  of 
professional  obligation  which  all  good  doctors  already  adhere  to. 
Indeed,  to  that  extent  and  in  this  respect  the  act  has  unquestionably 
leveled  up  the  standard  of  medical  service  which  is  given  in  Eng¬ 
land;  and  to  this  there  can  certainly  be  no  honest  objection. 

In  short,  the  contract  is  a  necessary  device  for  defining  the  extent 
to  which  the  Government  and  the  insured  patient  may  call  upon  the 
doctor  in  return  for  a  prescribed  sum.  That  this  should  lower  the 
dignity  of  the  doctor’s  status  is  no  more  thought  of  today  in  Eng¬ 
land  than  it  would  be  thought  of  in  any  way  compromising  to  pro¬ 
fessional  integrity  to  take  the  oaths  of  allegiance,  etc.,  necessary  to 
becoming  an  army  doctor. 

5.  Administration  of  Cash  Benefits 

The  cash  benefit  is  administered  through  the  approved  societies, 
except  in  the  case  of  the  300,000  “  post  office  contributors,”  who 

8  Manchester  Insurance  Committee — Terms  of  Service  for  Insurance  Prac¬ 
titioners,  January  31,  1920. 


27 


may  collect  through  the  local  post  offices  benefits  to  the  amount  of 
their  contributions. 

A  brief  explanation  of  the  machinery  will  serve  to  show  the  part 
played  by  these  societies.  They  are  the  official  carriers.  A  worker 
must  join  one  of  them  (or  become  a  deposit  contributor  at  the  post 
office).  He  then  receives  from  his  society  a  stamp  card,  which  he 
gives  to  his  employer  to  stamp  as  evidence  of  payment  by  him  of 
contributions  for  himself  and  his  employees.  These  stamp  cards, 
one  for  each  six  months,  are  returned  to  the  worker  at  the  end 
of  the  half  yearly  period ;  who  in  turn  sends  his  card  to  his  approved 
society,  which  credits  him  with  the  payment  and  presents  the  cards 
to  the  Government  as  evidence  of  the  collection. 

When  the  worker  wants  cash  benefits  he  gets  his  medical  certifi¬ 
cate  of  illness  from  his  doctor,  and  sends  it  along  to  the  approved 
society,  usually  by  presenting  it  locally  to  an  agent,  who  forwards 
the  claims. 

Since  the  approved  societies  are  organized  in  different  ways — 
some  in  local  lodges,  some  in  central  organizations  with  merely  local 
agents —  the  promptness  with  which  claims  are  settled,  the  standard 
of  eligibility  for  benefit,  and  the  thoroughness  with  which  a  local 
visitor  investigates  each  case,  in  addition  to  forwarding  the  doctor’s 
certificates  to  the  central  office,  vary  greatly. 

Moreover,  since  each  worker  may  join  any  approved  society  he 
wishes,  it  is  not  unusual  to  find  in  one  shop  workers  who  belong  to 
from  twenty-five  to  fifty  different  approved  societies.  It  is  the  mul¬ 
tiplicity  of  societies  which  makes  it  necessary  and  convenient  to  use 
the  stamped  cards  as  evidence  of  payment.  And  when  it  comes  to 
payment  of  benefits,  this  multiplicity  may  make  it  necessary  for  the 
agents  and  sick  visitors  of  a  great  number  of  approved  societies  to  be 
visiting  in  the  course  of  one  day  in  the  same  street  or  even  in  the 
same  house. 

The  frightful  waste  to  which  this  overlapping  leads  is  at  once 
apparent.  So  important  a  feature  of  the  act  are  these  approved 
societies,  however,  that  further  discussion  of  them  is  postponed  to 
a  separate  section. 

As  already  intimated,  the  diversity  of  standards  set  up  by  the 
approved  societies  means  that  some  societies  are  making  every  effort 
to  curtail  payments  while  others  are  giving  benefits  almost  without 
question.  The  element  of  control  which  is  counted  on  by  the  central 
governmental  authority  to  keep  the  payment  of  benefits  within  rea¬ 
sonable  limits  is  provided  by  considering  each  society’s  finances 


28 


autonomously.  The  act  provides  that  the  surplus  of  any  society 
(as  determined  by  the  government  valuation  taken  every  five  years) 
shall  be  available  for  increased  benefits  for  the  members  of  that 
society.  These  increased  benefits  may  be  in  the  form  of  either  cash 
or  medical  benefits.  Whether  or  not  this  provision  has  acted  as 
an  effectual  check  upon  liberality  of  payments,  is  doubtful.  For 
the  government,  although  careful  in  its  inspection,  has  on  the  other 
hand  made  special  and  additional  financial  provisions  for  societies 
which  become  insolvent. 

Another  provision  relating  to  the  control  of  approved  societies’ 
administrative  expenses  says  that  if  they  go  above  5  shillings  per 
person  per  year  there  shall  be  an  assessment  upon  the  members  of 
that  fund  or  their  benefits  may  be  correspondingly  reduced. 

There  has  been  some  criticism  on  the  score  of  delay  in  payment 
of  cash  benefits.  There  is  undoubtedly  some  ground  for  this  com¬ 
plaint,  although  here  again  much  of  the  criticism  can  be  explained 
in  terms  of  the  disorganized  clerical  staffs  of  the  approved  societies 
during  the  war  (e.  g.,  one  large  society  lost  100  men  clerks  the  day 
war  was  declared).  Or,  in  the  second  place,  delay  in  settlement  is 
frequently  to  be  explained  because  of  some  irregularity  in  the  pre¬ 
sentation  of  the  claim  for  which  the  approved  society  is  not  respon¬ 
sible.  Here  again  the  machinery  of  the  stamp  cards  causes  con¬ 
fusion,  as  for  example,  when  the  worker  unwittingly  gives  his  card 
to  the  agent  of  a  society  to  which  he  does  not  belong  and  the  card 
is  put  aside  by  the  agent  or  lost  in  the  offices  of  his  company. 

In  general,  however,  the  largest  carriers,  especially  the 
friendly  and  big  trade  union  societies,  pride  themselves  upon  the 
efficiency  of  their  office  organization  and  the  promptness  with 
which  claims  are  paid.  It  was  the  usual  thing  in  a  number  of  the 
societies  visited,  to  have  all  the  claims  received  in  a  morning’s 
mail  handled  and  dispatched  the  same  day.  Testimony  is  gen¬ 
eral,  however,  that  the  commercial  companies  which  are  acting 
as  approved  societies  are  the  least  satisfactory  carriers  from  the 
point  of  view  of  prompt  payment — due  perhaps  less  to  intention 
than  to  the  fact  that  the  health  insurance  is  only  incidental  to 
their  profit-making  business. 

It  may  be  said,  in  short,  that  most  of  the  administrative  difficulties 
surrounding  the  present  method  of  paying  cash  benefits  are  not 
inherent  parts  of  a  soundly-organized  insurance  plan,  but  they  are 
inherent  parts  of  a  method  of  paying  through  approved  societies 


29 


such  as  England  felt  compelled  to  resort  to  because  of  the  strength 
of  the  commercial  insurance  companies  and  friendly  societies. 

6.  Administration  of  Medical  Benefits 

Because  it  seemed  expedient  to  work  the  cash  payments  through 
approved  societies  and  because  they  had  available  no  adequate 
administrative  machinery  for  the  provision  of  medical  treatment,  it 
was  necessary  for  England  to  set  up  separate  machinery  for  the 
administration  of  medical  benefits.  The  country  was  therefore 
divided  into  about  150  local  areas,  in  each  of  which  an  insurance 
committee  was  created,  the  membership  of  which  is  representative 
of  the  different  interested  groups.  This  insurance  committee  makes 
the  contracts  with  the  local  doctors  who  are  to  serve  in  that  area. 
It  also  decides  how  many  insured  persons  may  be  on  the  list  of  any 
one  insurance  doctor,  although  a  maximum  of  3,000  persons  has 
now  been  set  by  the  Government.  This  committee,  moreover, 
handles  the  transfers  of  insured  persons  from  the  list  of  one  doctor 
to  another ;  receives  and  deals  with  complaints  against  the  insurance 
doctors ;  makes  the  payments  to  the  doctors ;  and  makes  arrange¬ 
ment  with  local  druggists  for  the  provision  of  drugs. 

The  means  at  the  disposal  of  these  committees  for  dealing  with 
inferior  or  inadequate  medical  service  are  by  no  means  completely 
satisfactory,  but  are  being  constantly  improved.  The  limitations 
of  the  size  of  the  panels  is  universally  felt  to  be  desirable,  as  is  also 
the  use  of  official  referees,  who  will  now  necessarily  work  in  close 
conjunction  with  insurance  committees. 

Actual  formal  complaints  against  insurance  doctors  by  insured 
persons  are  remarkably  rare,  due  perhaps  rather  to  the  cumbersome¬ 
ness  of  the  machinery  and  the  difficulty  of  proving  a  case,  than  to  the 
absence  of  criticism.  And  it  frequently  works  out  in  practice  that 
the  insured  persons  complain  to  the  approved  society  with  which 
they  feel  on  better  terms  than  to  the  insurance  committee;  and  the 
approved  society  then  handles  the  complaint  if  it  is  serious.  If  the 
insurance  committee  finds  that  there  are  grounds  for  the  complaints 
which  it  receives,  it  may  discipline  the  doctor  in  any  one  of  several 
ways,  the  most  drastic  of  which  is  to  cancel  his  contract. 

In  such  a  case,  however,  the  doctor  has  the  right  to  appeal  to  a 
disinterested  local  body  composed  of  three  medical  men  and  a  bar¬ 
rister  as  chairman. 

To  safeguard  the  interests  of  the  insured  person  who  would 
assure  himself  of  satisfactory  medical  service,  the  following 
methods  are  provided:  He  has  free  choice  of  doctors;  the 


30 


chance  periodically  to  change  his  doctor ;  and  the  right  to  com¬ 
plain  to  an  authority, — the  local  insurance  committee. 

In  practice,  the  first  provision — free  choice  of  doctors — means 
today  as  much,  if  not  more,  actual  freedom  in  selection  than 
obtained  before  the  act  was  passed.  For  in  the  great  majority  of 
cases  those  doctors  who  were  already  practicing  in  industrial  or 
agricultural  centers  became  insurance  doctors.  And  in  some  dis¬ 
tricts  the  assurance  of  a  fixed  income  from  insurance  practice  has 
meant  that  additional  doctors  have  been  attracted  there  to  practice. 

The  clamor  for  “  free  choice  of  doctors  ”  was  not  one,  however, 
which  was  or  is  raised  by  the  patients,  although  it  goes  without 
saying  that  the  most  successful  medical  work  depends  upon  a  condi¬ 
tion  of  personal  confidence  between  doctor  anVl  patient.  But  there  is 
very  much  less  interest  on  the  part  of  the  insured  persons  in  exercis¬ 
ing  a  free  choice  than  was  anticipated.  The  great  problem  has, 
indeed,  been  to  get  workers  to  indicate  a  preference  for  some  doctor, 
in  order  that  they  may  be  assigned  to  a  place  on  that  doctor’s  list. 
It  is  a  further  consideration  that  the  free  choice  may  take  place  on 
a  capricious  basis.  Mention  was  frequently  made  of  cases  where  a 
popular  doctor  on  a  convenient  corner  had  larger  panels  than  he 
could  handle  properly,  while  better  doctors,  who  were  less  genial  or 
lived  on  a  side  street,  had  less  to  do  than  they  could  take  care  of. 

Once  the  insured  person  is  on  a  given  doctor’s  list  and  finds  the 
medical  service  unsatisfactory  (even  though  there  may  not  be  suffi¬ 
cient  ground  for  official  complaint),  he  may  apply  for  transfer  to  the 
list  of  another  doctor.  Such  transfer  may  take  place  at  th.fend  of 
any  six  months’  period ;  or,  if  the  original  insurance  doctor  also 
signs  the  application,  the  insured  may  transfer  at  once.  Manifestly, 
however,  the  latter  condition  is  difficult  to  fulfill ;  and  the  former  is 
resorted  to  in  surprisingly  few  cases. 

7.  Payment  of  Doctors 

The  basis  for  the  payment  of  doctors  is  11  shillings  ($2.75) 
per  insured  person  per  year  to  which  in  the  rural  areas  are 
added  mileage  fees  for  distances  of  over  two  miles  to  the 
patients’  homes.  A  doctor  with  a  thousand  persons  on  his  list 
would  thus  have  an  assured  income  of  about  $2,750.  (This 
would  mean  over  $3,000  if  considered  from  the  point  of  view  of 
the  comparative  purchasing  power  of  money  in  England  and 
in  America)  to  which  would  be  added  his  fees  for  private  prac¬ 
tice.  It  is  admitted  by  doctors  and  affirmed  by  all  observers 
that  the  doctors  are  thus  better  off  under  the  act  than  they  ever 


31 


were  before.  They  do  not  have  to  worry  about  collecting  fees 
from  panel  patients ;  they  get  their  insurance  income  at  regular 
intervals  of  three  months ;  they  are  virtually  guaranteed  an  income 
dependent  upon  the  size  of  the  panel.  Now  that  the  practice  of 
doctors  working  in  partnership  with  several  colleagues  is  being 
extended,  the  time  on  duty  is  being  divided  up  in  a  way  to  make 
the  amount  of  work  necessary  to  earn  a  comfortable  living  exceed¬ 
ingly  reasonable,  leaving  time  for  study  and  recreation. 

Some  trouble  still  arises  about  the  number  and  identity  of 
insured  persons  on  a  doctor’s  list  but  difficulties  on  that  score 
are  being  reduced.  The  doctor  is  paid  on  the  basis  of  a  list 
made  up  in  advance,  and  if  there  are  transfers  or  movement  of 
persons  an  adjustment  is  effected  at  the  end  of  the  period.  Here 
again  it  seems  true  that  doctors  are  on  the  whole  less  particular 
than  they  used  to  be  about  being  sure  that  the  patients  whom  they 
treat  are  on  their  own  panel.  If  the  visitor  to  a  doctor’s  office 
needs  attention  he  is  likely  to  get  it;  or  he  is  sent  where  he  can 
get  it. 

The  present  so-called  capitation  basis  of  payment  has  the  effect 
of  making  it  an  object  for  the  doctor  to  keep  his  insured  patients 
well  and  of  getting  them  well  as  quickly  as  possible.  Of  course, 
there  is  also  possible  the  view  that  since  the  fee  is  assured  the 
service  will  not  be  so  good.  Undoubtedly,  instances  to  illustrate 
both  tendencies  could  be  cited.  But  on  the  whole  it  is  agreed  that 
the  capitation  basis  is  the  most  satisfactory. 

In  Manchester  and  Salford,  the  doctors  originally  objected  to 
the  capitation  plan  and  a  basis  of  payment  for  services  rendered 
was  adopted.  A  similar  plan  started  in  four  other  localities  has 
been  dropped.  The  plan  provides  a  scale  of  fees  for  different  types 
of  visit  and  a  full  record  by  the  insurance  doctor  of  services  ren¬ 
dered  by  him.  The  records  pass  through  the  hands  of  a  committee 
of  doctors  to  see  that  there  has  not  been  excessive  visitation  and 
the  payments  are  then  made.  The  total  fund  from  which  payment 
comes,  however,  is  determined  on  the  capitation  basis ;  that  is,  it  is 
as  many  times  11  shillings  as  there  are  insured  persons  in  the 
entire  district;  so  that  no  doctor  gets  more  in  the  long  run  than 
he  would  in  any  other  district — unless  he  happens  to  be  working 
in  an  area  where  the  rate  of  sickness  is  constantly  excessive.  Since 
the  total  resources  are  thus  limited,  it  has  thus  far  under  the  visita¬ 
tion  basis  been  necessary  at  every  settlement  to  discount  the  doc¬ 
tors’  claims  for  remuneration.  The  result  naturally  is  that  the  good 
doctors  who  find  their  bills  discounted  because  their  colleagues  have 


32 


been  doing  too  much  visiting  and  are  thus  making  large  claims, 
inquire  into  the  type  of  medical  service  being  rendered.  Whether 
the  reason  for  this  discounting  of  claims  is  that  the  scale  of  fees 
for  the  several  services  is  high  or  that  the  doctors  do  too  much 
visiting,  it  is  impossible  to  say.  The  doctors  themselves,  however, 
and  others  in  the  Manchester  district,  believe  in  the  system  and 
say  that  it  works  to  satisfaction.  It  has  the  good  result,  they  con¬ 
tend,  of  paying  for  work  done  and  thus  encouraging  good  work 
where  it  is  needed.  Not  the  size  of  the  panel,  but  the  rate  of  sick¬ 
ness  should  in  this  view  determine  the  payment. 

The  capitation  basis,  however,  is  clearly  the  simpler  of  the 
two;  requiring  less  check  and  oversight,  and  giving  the  benefit  of 
a  guaranteed  amount  of  income  and  of  freedom  to  give  all  the 
medical  attention  necessary  without  thought  of  seeming  to  “  over- 
visit.”  And  in  the  last  analysis  the  kind  of  medical  attendance 
given  is  determined  more  by  the  education  and  morale  of  the  pro¬ 
fession  than  by  the  method  of  compensation. 

The  English  experience  in  administering  medical  benefits 
thus  confirms  the  case  for  (1)  local  administration  of  the  medical 
service;  (2)  for  a  uniform  basis  for  contracts  with  the  local 
doctors  in  all  districts;  (3)  for  a  uniform  basis  for  certification 
as  to  physical  condition  justifying  cash  benefits ;  (4)  for  medical 
referees;  (5)  for  co-operative  use  of  local  diagnostic  clinics. 

8.  Drugs 

A  prescribed  number  of  drugs  and  medical  appliances  are  avail¬ 
able  free  on  prescription  from  the  insurance  doctor.  These  pre¬ 
scriptions  when  filled  are  forwarded  to  the  insurance  committees 
who  make  the  payments  to  the  local  chemists  whom  they  have  ap¬ 
pointed  to  fill  the  insurance  prescriptions,  on  the  basis  of  charges 
which  have  been  agreed  to  between  the  Government  and  the  national 
pharmaceutical  organization. 

In  the  event  that  a  doctor  is  found  to  be  giving  too  many  pre¬ 
scriptions  or  those  calling  for  too  expensive  drugs  for  which  equally 
good  but  cheaper  substitutes  are  available,  he  may  be  brought  before 
a  committee  of  doctors  to  explain  his  conduct. 

In  practice,  however,  the  administration  of  the  drug  provisions 
of  the  act  gives  rise  to  little  difficulty  and  is  considered  to  be  run¬ 
ning  smoothly.  Criticism  under  this  head — as  with  the  other  fea¬ 
tures  of  the  act — fastens  rather  upon  the  small  number  of  items 
and  appliances  made  freely  available  to  the  insured  as  their 
statutory  right. 


33 


9.  Approved  Societies 

The  use  of  the  approved  societies  as  carriers  of  the  cash 
benefits  has  been  an  expedient  but  in  many  ways  unfortunate 
procedure.  Certainly  no  other  country  seeing  the  extra  expense, 
duplication  and  over-lapping  caused  by  the  present  system  should 
think  of  resorting  to  this  method  of  handling  the  cash  benefits. 

There  are  now  over  900  approved  societies  and  there  were  at 
one  time  over  2,000,  many  of  which  have  been  consolidated  with 
other  funds. 

Each  society,  of  course,  has  its  own  central  office,  its  own  local 
agents  and  sick  visitors.  Accounts  must  be  kept  for  it  separately 
in  the  Government  offices  and  there  must  be  individual  supervision 
of  their  activities.  Some  societies  select  their  risks ;  others  admit 
every  applicant.  There  is  comparatively  little  segregation  of  risks 
by  occupation  and  no  segregation  by  residence.  The  statistics 
which  would  show  the  incidence  of  sickness  by  occupation  and 
locality  are  thus  especially  difficult  to  get. 

In  short,  the  whole  approved  society  machinery  is  a  fine  example 
of  what  to  avoid. 

Indeed,  there  are  not  lacking  signs  that  the  English  themselves 
would  be  glad  to  be  rid  of  them  and  to  administer  the  insurance 
through  one  national  fund.  The  valuation  of  approved  societies 
which  is  now  nearing  completion  will  undoubtedly  reveal  wide  dif¬ 
ferences  in  the  amount  of  surplus  which  will  be  available  for  in¬ 
creased  benefits  in  the  several  societies.  If  it  comes  about  that  some 
of  the  strongest  commercial  companies  and  friendly  societies  are 
in  a  position  to  offer  larger  benefits  than  many  of  the  other  societies, 
there  will  undoubtedly  be  considerable  objection  from  the  trade 
unions.  And  it  is  openly  hinted  even  in  official  quarters  that  in  the 
event  of  such  a  wide  discrepancy  being  revealed,  the  agitation  for 
one  national  fund  as  the  carrier  would  be  very  active. 

Certainly  the  warning  was  again  and  again  repeated  to  us :  “If 
you  go  in  for  health  insurance,  don’t  have  anything  to  do  with 
approved  societies.” 


10.  Hospitals 

As  already  stated,  no  hospital  treatment  is  given  under  the  act. 
The  doctor  who  wants  his  patient  to  have  institutional  care  must 
get  him  into  a  voluntary  hospital.  Of  late  years  this  has  been  in¬ 
creasingly  difficult  because  of  a  shortage  of  beds  and  now  also 
because  the  hospitals  are  financially  embarrassed.  Costs  have  more 


34 


than  doubled,  former  contributors  are  now  taxed  so  heavily  that 
they  do  not  give ;  contributors  from  among  the  “  new  rich  ”  have 
not  yet  materialized.  As  one  advocate  of  privately  supported  hos¬ 
pitals  naively  remarked  to  us :  “  We  expect  that  in  another  ten 

or  twelve  years  the  new  rich  will  get  the  habit  of  giving  and  then 
the  hospitals  will  be  all  right/’ 

But  meanwhile  frantic  efforts  are  being  made  to  keep  the  hospital 
doors  open  at  all ;  and  those  who  are  planning  the  public  health  pro¬ 
gram  of  the  country,  see  that  a  wholly  new  way  of  meeting  the 
problem  is  essential.  It  is  possible  that  the  Government  will  in  the 
near  future  abolish  the  poor  law  hospitals  and  make  their  beds 
available  for  use  by  the  local  authorities.  It  is  also  possible  that 
the  Government  will  subsidize  the  hospitals  on  the  basis  of  the  num¬ 
ber  of  beds  used  by  insured  patients.  If  some  such  arrangements 
as  this  are  made,  it  will  be  then  necessary  to  take  steps  to  pay  the 
hospital  doctors  who  now  give  their  services ;  as  it  is  clear  and  right 
that  if  the  hospitals  are  to  be  paid  for  their  work  for  the  insured, 
the  consultants  should  be  paid  also. 

This  is  an  admittedly  transitional  time  in  respect  to  hospital  pro¬ 
visions,  and  those  who  are  anxious  to  see  adequate  provision  made 
as  soon  as  possible  with  no  suggestion  of  charity  about  it,  are  advo¬ 
cating  that  the  hospitals  be  operated  as  public  institutions.  This  will 
undoubtedly  come  in  time,  although  the  Minister  of  Health  has 
officially  stated  that  this  is  not  the  present  Government  program. 
Nevertheless  the  trend  is  already  toward  wholly  publicly  supported 
institutions  for  tuberculosis  and  maternity ;  and  a  good  number  of 
municipalities  have  their  own  general  hospitals. 

At  the  end  of  August  of  this  year  (1920),  the  Minister  of  Health 
introduced  a  bill  which  is  likely  to  become  a  law,  which  aims  to 
make  a  beginning  at  public  support  and  control  of  the  hospitals. 
The  proposed  legislation  gives  power  to  county  authorities  to  supply 
and  maintain  hospitals,  to  contribute  to  hospitals,  to  undertake  the 
maintenance  of  any  poor  law  hospitals  in  their  areas,  to  provide 
ambulance  service.  It  also  gives  these  authorities  power  to  raise 
the  necessary  funds. 

The  element  of  national  control  begins  to  enter,  for  contributions 
out  of  county  funds  to  voluntary  agencies  are  only  allowed  “  on 
such  terms  and  conditions  as  may  be  approved  by  the  Minister.” 

This  legislation  is  obviously  a  temporary  and  temporizing  manner 
of  dealing  with  the  shortage  of  hospitals,  since  it  puts  the  whole 
financial  burden  on  the  counties  while  making  possible  a  beginning 
of  national  oversight.  Still  further  legislation  from  the  national 


35 


point  of  view  is  thus  needed,  and  is  probably  contemplated  in  con¬ 
nection  with  a  bill  to  transform  the  poor  law  institutions  into  general 
municipal  agencies. 


11.  Tuberculosis 

At  present  provision  is  made  under  the  act  for  the  sanatorium 
treatment  of  insured  persons  having  tuberculosis.  This  arrange¬ 
ment  will  be  discontinued  after  the  year  1920,  not  because  it  is  no 
longer  needed,  but  because  it  is  felt  that  the  local  authorities  can 
handle  this  disease  better  and  more  adequately.  For  then  the  whole 
population  will  be  considered  at  once  from  the  point  of  view  of 
institutional  care  of  tuberculosis,  rather  than  be  treated  in  two 
groups — the  insured  and  the  non-insured.  Domiciliary  treatment 
for  this  disease  remains,  however,  the  duty  of  the  insurance  doctor. 

Admittedly  the  present  provisions  are  too  few ;  almost  every  in¬ 
surance  committe  has  a  waiting  list  for  sanatorium  treatment.  To 
pass  on  to  the  local  authorities  the  work  of  maintaining  all  the  sana¬ 
torium  beds  necessary  for  tuberculosis  will,  therefore,  not  solve  the 
problem.  As  was  said  above  with  relation  to  general  hospitals,  it 
will  be  necessary  in  the  immediate  future  for  the  Ministry  of  Health 
in  conjunction  with  the  local  authorities,  to  adopt  a  policy  which 
will  really  promise  to  cope  with  this  enormous  problem. 

Interesting  experiments  are  being  made  in  the  organizing  of  self- 
supporting  farm  colonies  for  tuberculosis  patients  who  have  had 
sanatorium  treatment  but  who  will  be  much  safer  and  healthier  if 
they  do  not  immediately  return  to  the  cities.  One  of  these  colonies 
just  out  of  Cambridge  in  Cambridgeshire  may  be  mentioned  as 
deserving  additional  study  at  the  hands  of  those  in  this  country 
who  are  carrying  on  the  community’s  attack  on  this  scourge. 

12.  Nursing 

No  nursing  services  are  provided  under  the  act  although  as 
already  pointed  out  they  were  contemplated  in  1914;  and  will  in  all 
probability  sooner  or  later  be  added.  The  nursing  situation,  like 
that  of  the  hospitals,  is  admittedly  unsatisfactory  and  in  a  transi¬ 
tional  state. 

Nursing  services  are  now  provided  by  “  local  authorities  in  con¬ 
nection  with  Tuberculosis  and  Infant  Welfare,  by  Parish  Councils 
for  the  supervision  of  children  under  the  Children  Act,  by  Educa¬ 
tion  Authorities  in  following  up  the  recommendations  as  to  treat¬ 
ment  made  by  School  Medical  Officers,  and  by  various  voluntary 
agencies.  With  such  a  plethora  of  authorities  it  is  to  be  expected 


36 


that  it  will  frequently  occur  that  two  or  more  nurses  will  at  one  and 
the  same  time  be  visiting  the  same  family/’9 

It  will  thus  be  seen  that  some  districts  are  adequately  staffed 
while  others  are  not ;  and  that  there  is  needed  a  proper  coordination 
of  national  and  local  policies  which  will  make  universally  available 
in  a  public  way  the  services  needed. 

13.  Prevention  and  Research 

The  claim  that  health  insurance  means  a  new  awareness  of  the 
value  of  preventive  medicine  has  on  the  whole  been  substantiated 
in  the  experience  of  Great  Britain,  although  the  developments  have 
perhaps  been  in  unforeseen  directions. 

It  may  be  fairly  said  that  the  Ministry  of  Health  which  was 
created  in  1919  grew  not  only  out  of  a  knowledge  of  the  need  for 
co-ordination  of  medical  efforts,  but  also  out  of  the  fact  that  a 
unified  national  health  program  and  administration  was  shown 
to  be  necessary  to  national  vitality  by  the  health  insurance  and 
by  the  army  draft. 

It  is  also  true  that  since  the  insurance  act  was  passed, 
measures  have  been  adopted  for  providing  separately  for 
venereal  disease,  for  tuberculosis,  for  maternity  and  child  welfare. 
How  much  of  a  causal  relation  exists  between  the  needs  revealed 
by  the  insurance  act  and  the  inception  of  these  services,  it  is 
impossible  to  say.  But  it  is  certain  that,  now  health  insurance 
is  a  fact,  there  is  a  new  impetus  and  eagerness  to  attack  the 
hospital,  nursing,  dental  and  sanatorium  problems  on  a  public 
and  fundamental  basis.  It  is  also  true  that  the  demand  for  a 
constructive  policy  worked  out  under  a  national  medical  service  is 
greater  than  it  would  have  been  today  had  there  been  no  insurance 
act.  And  the  doctors  have  certainly  come  a  long  way  toward  their 
new  attitude  regarding  preventive  medicine,  toward  clinical  co¬ 
operation  and  toward  regarding  themselves  as  custodians  of  the 
health  of  the  community  as  well  as  the  curers  of  its  ills.  This 
change  of  outlook,  this  invaluable  educational  process,  can  be 
ascribed  almost  wholly  to  the  experience  they  have  gained  in  work¬ 
ing  the  insurance  act. 

It  is,  moreover,  now  widely  realized  that  the  tuberculosis  as  well 
as  other  sickness  cannot  be  greatly  reduced  until  the  housing  prob¬ 
lem  of  the  country  is  seriously  faced  on  a  large  scale. 

It  was  to  have  been  expected,  however,  that  the  records  of 
sickness  would  reveal  local  problems  and  occupational  exposures 
which  needed  special  attention.  Medical  records  were  required  of 


*A  Public  Medical  Service,  by  David  McKail  and  William  Jones. 


37 


the  insurance  doctors  until  the  war  when  they  were  abandoned, 
and  only  at  the  present  time  is  attention  being  given  to  devising  a 
record  card  that  will  be  of  value.  For  it  is  admitted  by  all  that  the 
pre-war  records  were  practically  valueless  as  disclosing  the  in¬ 
cidence  and  nature  of  the  country's  sickness. 

In  short,  after  eight  years  of  the  insurance  act,  there  is  not  a 
definite  body  of  knowledge  as  to  which  localities,  trades  or  age 
groups  experience  which  particular  kinds  of  illness.  But  here  again, 
extraordinary  as  this  omission  seems,  it  must  be  remembered  that 
through  five  war  years  the  doctors  who  remained  in  civil  life  hardly 
had  time  to  see  all  the  patients  who  needed  attendance  to  say 
nothing  of  trying  to  keep  individual  records. 

On  the  side  of  research  the  results,  although  only  indirectly 
attributable  to  the  health  insurance,  have  been  most  valuable.  A 
Medical  Research  Committee  was  organized  at  an  early  date  after 
the  act  was  passed ;  and  during  the  war  that  committee  became 
the  official  research  body  of  the  Government  under  which  worked 
the  Health  of  Munitions  Workers’  Committee  and  others.  Its  find¬ 
ings,  reported  in  full  in  special  monographs  and  in  its  very  inter¬ 
esting  annual  reports,  have  been  of  great  medical  value;  and  the 
chief  problem,  as  was  pointed  out  by  the  secretary  of  the  Committee, 
is  to  get  the  information  obtained  by  research  quickly  into  the 
hands  of  all  the  general  practitioners  of  the  land. 

So  important  has  become  the  work  of  this  Committee  that  it 
has  now  become  the  Medical  Research  Council,  removed  from 
under  the  jurisdiction  of  the  Ministry  of  Health  (for  reasons  which 
seem  to  the  outsider  hardly  sufficient),  and  placed  directly  under 
the  Privy  Council. 

On  the  whole,  considering  the  intervening  problems,  the  work 
of  fostering  preventive  measures  and  research  has  gone  well;; 
although  it  is  a  matter  of  great  regret  that  the  original  form  of 
medical  record  keeping  was  not  well  enough  designed  to  be  of  per¬ 
manent  use,  and  that  the  body  of  existent  records  is  so  meager. 

Not  the  least  significant  of  the  preventive  influences  which  have 
been  set  in  motion  are  two  reports,  one  by  Sir  George  Newman, 
Chief  Medical  Officer  of  the  Ministry  of  Health,  on  “  An  Outline 
of  the  Practice  of  Preventive  Medicine;”10  the  other  the  Interim 
Report  of  the  Consultative  Council  on  Medical  and  Allied  Services 
on  the  “  Future  Provisions  of  Medical  and  Allied  Services.”11 

10Cmd.,  363. 

nCmd.,  693.  This,  and  the  report  referred  to  in  footnote  10,  may  be 
ordered  by  the  code  numbers  given  at  a  nominal  cost  from  H.  M.  Stationery 
Office,  Imperial  House,  Kingsway,  London,  W.  C.  2. 


38 


These  reports  have  had  a  wide  reading  and  are  in  harmony 
on  their  major  recommendation,  although  the  latter  carries  its  con¬ 
structive  proposals  into  greater  detail.  They  emphasize  the  strategic 
place  in  a  national  public  health  program  of : 

1.  The  general  practitioner  as  the  first  and  major  point  of  contact  with 
the  people; 

2.  The  primary  (or  local)  health  center  as  the  unit  of  local  medical 
work  especially  on  its  diagnostic  and  specialist  side  although  the  members  of 
the  clinic  would  be  largely  local  general  practitioners ; 

3.  The  secondary  (or  district)  health  center  with  salaried  specialists 
and  consultants  having  necessary  hospitals  and  laboratories ; 

4.  A  number  of  supplementary  services  and  special  hospitals ; 

5.  A  better  integration  of  medical  education  with  the  day-by-day  work 
of  the  general  practitioner. 

Their  conclusions  as  to  general  principles  and  as  to  methods  of 
carrying  them  into  practical  effect  seem  to  your  investigators  to  be 
sound  and  to  warrant  the  further  study  of  your  Commission.  Two 
copies  of  each  accompany  this  report. 


14.  Insurance  Finances 

The  sources  of  income  for  the  insurance  expenses  are  the 
following: 

1.  Contributions  of  employers  and  employed. 

2.  Contributions  of  the  State  under  the  act. 

3.  Supplementary  Grants  of  Parliament  for  Women’s  Equalization  Fund ; 

and  for  the  Central  Fund. 

4.  Parliamentary  Grants  as  follows : 

a.  Medical  Grants  in  Aid  (under  Act  of  1913). 

b.  Special  Grants  in  Ministry  of  Health  Budget  for  Central 

Administration. 

c.  Special  Grants  for  Expenses  of  Insurance  Committee. 

The  sources  of  expenses  under  the  insurance  act  are  as 
follows : 

1.  Cash  Benefits. 

2.  Doctors’  Fees. 

3.  Administration  Expenses  of 

a.  Approved  Societies. 

b.  Insurance  Committees. 

c.  Central  Administration. 

4.  Drug  Fund 

5.  The  Reserve  Fund 

6.  The  Contingencies  Fund. 

7.  Women’s  Equalization  Fund. 

8.  Central  Fund. 


39 


In  explanation  of  the  above  two  paragraphs  it  will  be  useful 
to  describe  those  funds  not  already  explained. 

The  Reserve  Fund  is  set  up  to  enable  the  insurance  fund  to 
pay  for  the  sickness  of  the  older  members.  The  statutory  contrib¬ 
utions  are  based  on  the  sickness  rate  of  16  years  of  age  and  until 
there  has  been  one  complete  generation  contributing  under  the 
act  it  is  necessary  to  create  a  reserve  to  meet  the  increased  incidence 
of  sickness  of  the  older  members  admitted  at  the  start.  The  fund 
is  based  on  a  complete  payment  by  1950. 

The  Contingencies  Fund  is  created  for  every  approved  society 
to  meet  any  extraordinary  demands  that  might  arise. 

The  Women’s  Equalization  Fund  is  to  pay  for  the  high  incidence 
of  sickness  of  married  women  workers,  which  the  societies  have 
found  it  necessary  to  provide  for. 

The  Central  Fund  is  to  provide  for  those  cases  where  an  ap¬ 
proved  society  shows  a  heavy  and  extraordinary  deficit. 

The  moneys  available  from  each  contribution  are  divided  as 
follows  for  men : 

Pence 

Sickness  Benefit  .  3.02  (per  cap.  per  week) 

Disablement  Benefit  .  1.11 

Maternity  Benefit  . 68 

Medical  Benefit  .  1.92 

Expenses  of  Administration  . 94 


Total  .  7.67 — 7  2/3  pence. 

To  Benefit  Fund  (including  administration)  . 7-2/3 

To  Contingencies  Fund  and  Central  Fund  .  2/3 

To  Redemption  of  Reserve  Fund  Value  . 1-2/3 


lOd. — total  of 
employer  and  employees’ 
contribution. 

But  the  expenses  under  the  act,  in  addition  to  requiring  2/9  of 
the  expense  of  benefits  to  be  borne  by  the  state,  necessitate  other 
appropriations. 

The  increased  doctors’  fee  now  makes  necessary  a  special  Ex¬ 
chequer  grant.  The  amount  of  this  grant  in  1919  was  £3,000,000; 
but  the  1920  figure  will  be  considerably  higher. 

The  Women’s  Equalization  Fund  comes  from  an  Exchequer 
grant  of  £280,000. 

The  expenses  of  administration  in  the  Ministry  of  Health  come 
(as  far  as  can  be  roughly  estimated  from  the  1920-21  budgets)  to 
something  over  £400,000. 


40 


The  statement  given  below  will  indicate  in  an  approximate 
way  only  the  aggregate  sums  involved  in  the  insurance  plan  for 
the  year  1920. 


Approximate  Balance  Sheet  of  Receipts  and  Expenditures  for  the  Opera¬ 
tion  of  the  Act  (1920) 12 


Receipts 

Expenses 

Contributions  of  Em¬ 

Benefits  (cash  and  medi¬ 

ployers  and  Employees 

£29,800,000 

cal)  . 

£28,700,000 

State  Grant  including 

Supplementary  Medical 

Supplementary  Grants 

(1919  basis)  . 

3,100,000 

on  Women’s  Equaliza¬ 

Central  Administration.. 

400,000 

tion  . 

6,900,000 

Contingencies  Fund . 

1,800,000 

Supplementary  Grant  for 

Reserve  Values  . 

1,500,000 

Medical  Services 
(1919  basis)  .  „ . 

3,100,000 

Reserve  Surplus  . 

6,000,000 

Interest  on  Cash  Re¬ 

serves  . 

2,000,000 

£41,800,000 

£41,500,000 

A  rough  check  of  this  balance  sheet  is  obtained  by  making  a  com¬ 
parative  study  of  the  Estimates  of  1920.  These  show  that  the  expense  of  the 
act  to  the  Government  and  payable  out  of  the  exchequer  is  between  eleven 
and  twelve  million  pounds  for  the  year.  Such  an  amount  added  to  the 
receipts  of  the  act  from  the  contributors  roughly  balances  the  total  expense 
of  the  act. 

I 

Another  sidelight  on  the  cost  of  the  act  was  supplied  by  the 
figures  of  Dr.  Addison,  the  Minister  of  Health,  in  reply  to  a  ques¬ 
tion  in  Parliament  on  July  19,  1920.  He  said  that  since  the  incep¬ 
tion  of  the  act  the  total  cost  was  in  round  numbers  190  million 
pounds.  Of  this  amount  99  million  pounds  had  gone  in  benefits; 
expenses  and  administration  had  taken  25  millions ;  and  there  was 
a  balance  in  reserve  of  60  millions. 

About  12  per  cent,  he  said,  of  the  receipts  from  contributions 
went  to  the  approved  societies  for  their  expenses  of  adminis¬ 
tration. 

As  far  as  it  is  safe  to  draw  any  conclusions  from  the  above 
figures,  they  indicate  that  to  provide  medical  service  for  about 
15  million  people  and  cash  benefits  to  the  amount  of  something 
over  15  million  pounds,  the  yearly  Government  expenditures 
is  about  12  million  pounds  and  the  cash  contributions  of  employer 

“This  statement  aims  to  give  only  the  most  general  approximation  of 
receipts  and  expenses.  It  includes  a  figure  for  the  supplementary  medical 
grant  which  is  probably  much  too  low  owing  to  the  fact  that  the  1920  medical 
oayment  is  at  the  new  rate  of  $2.75  per  insured. 


41 


and  the  workers  are  something  over  29  million  pounds.  And  it 
has  so  far  cost  one  pound  for  administration  for  every  four  pounds 
expended  on  benefits. 

It  would  seem  to  be  fair  to  draw  the  conclusion  that  for  the 
benefit  of  15  million  peoples’  health,  about  205  million  dollars  (in 
terms  of  American  currency)  per  year  is  being  spent;  or  between 
$13  and  $14  per  insured  person  per  year.  If  these  figures  are  at 
all  accurate,  the  total  outlay  appears  large  for  the  benefits  received. 

In  a  careful  study  of  “A  Public  Medical  Service”  (Allen  & 
Unwin),  1919,  made  by  a  Glasgow  doctor  and  the  Clerk  of  the 
Glasgow  Insurance  Committee,  the  case  is  set  forth  with  a  con¬ 
vincing  show  of  accurate  statistics  for  a  truly  public  medical  service 
(cash  benefits  excepted),  which  would  cost  between  12  and  13 
shillings  per  person  per  year — or  a  little  over  $3.  The  additional 
cost  necessary  to  pay  cash  insurance  claims  would  certainly  not 
amount  to  over  $5  (probably  $4  would  be  much  more  nearly  a 
correct  figure  on  the  basis  of  the  amount  of  the  English  benefits)  ; 
making  a  total  cost  of  less  than  $10  per  capita  for  medical  and 
institutional  treatment  available  for  the  entire  population  with 
the  addition  of  cash  benefits  of  the  amount  specified  in  the  British 
act. 

These  figures  are  introduced  as  being  in  no  sense  exact  or  con¬ 
clusive.  But  they  are  believed  to  indicate  that  the  present  methods 
of  an  insurance  scheme  with  duplicating  approved  societies, 
elaborate  doctors’  panels,  government  inspecting  agencies  and  small- 
scale  private  druggists,  create  a  variety  of  channels  for  small  wastes 
and  leakages,  which  in  the  aggregate  amount  to  an  unwarrantedly 
high  expense  for  the  value  received. 

Moreover,  it  is  obvious  that  the  method  of  financing  the 
measure  has  now  departed  (if  indeed  it  ever  was  so  financed) 
from  an  insurance  basis.  Special  funds  are  created  and  new 
costs  are  added  with  no  regard  to  the  amounts  originally  made 
available.  This  is  not  said  in  objection  to  the  present  method 
of  financing  by  supplementary  grants.  But  it  is  a  further  point 
in  the  evidence  that  the  tendency  is  increasingly  away  from  an 
insurance  and  toward  a  public  health  basis  of  finance,  so  that  the 
funds  are  made  available  on  a  basis  of  public  need  rather  than 
solely  on  a  basis  of  joint  contribution  and  a  pooled  risk. 


42 


V.  Conclusions 


THE  general  conclusions  reached  by  your  investigators  were 
somewhat  summarily  stated  at  the  outset.  But  it  may  not 
be  out  of  place  to  consider  finally  some  of  the  more  specific  results 
of  the  British  experience  from  which  America  might  especially 
profit. 

A.  The  application  of  the  insurance  method  to  the  provisions 
of  medical,  hospital  and  nursing  facilities  is  a  clumsy  and  indirect 
way  of  making  sure  that  the  public  health  is  being  fostered  and 
conserved. 

The  tendency  is  a  wise  one  which  brings  a  separation  between 
the  medical  services  which  should  be  universally  available  and  the 
cash  benefits  which  might  remain  on  an  insurance  basis. 

On  the  other  hand,  it  is  undoubtedly  true  that  the  immediate 
expense  to  the  public  treasury  can  be  kept  considerably  reduced 
by  securing  payment  for  the  medical  services  out  of  the  fund 
created  by  the  joint  contributions. 

And  it  is  further  true,  not  only  in  England  but  wherever 
health  insurance  has  been  instituted,  that  the  working  of  the 
insurance  has  supplied  the  great  education  to  all  groups  in  the 
community  but  especially  to  the  doctors,  as  to  the  necessity  for 
.  a  more  extensive  public  health  program. 

Hence,  as  a  practical  matter,  the  incorporation  of  the  medical 
benefits  into  the  insurance  act  is  probably  a  wise  step  coupled 
with  which  should  be  the  extension  of  these  benefits  under  the 
act  to  all  dependents. 

B.  The  public  health  provisions  of  the  community  should  as 
soon  as  possible  include  the  following: 

Medical  attendance  for  all  sick  members  of  the  community  who 
desire  it  (including  general  practitioner  and  consultant  services)  : 

Institutional  treatment  including  hospitals,  sanataria  and  con¬ 
valescent  homes; 

Medicine  and  medical  appliances ; 

Dental  treatment,  nursing ;  and 

All  medical  services  incident  to  maternity. 

These  provisions  should  be  available  on  a  basis  of  joint  state 
and  local  support  with  the  actual  administration  of  the  work  as 
the  responsibility  of  the  local  health  authorities,  who  would  be  so 
organized  or  reorganized  as  to  be  able  to  include  the  above  services 
under  their  care. 

Plans  for  the  relation  of  local  to  district  medical  facilities  have 
'  been  admirably  worked  out  in  one  or  two  English  counties  and  their 
method  of  organization  suggests  a  model  for  careful  consideration. 


43 


As  illustrative  of  the  method  there  in  use,  the  plan  given  below  13 
is  valuable : 

1.  The  authority  for  carrying  out  the  scheme  will  be  a  Board 
consisting  of  representatives  of  the  County  Council  and  of  the 
General  Hospitals. 

2.  The  General  Hospital  areas  shall  be  those  shown  on  the 
sketch  plan,  subject  to  such  modifications  as  experience  shall  show 
to  be  necessary. 

3.  In  each  Hospital  area  an  Advisory  Committee  shall  be 
formed  of  members  of  the  Hospital  Staff  and  Medical  Officers  in 
charge  of  the  out-stations,  whose  duties  will  embrace — 

a.  Ensuring  that  all  treatment  given  at  the  out-stations  is 

effective,  and 

b.  Advising  the  Board  of  Representatives  on  all  medical 

matters,  including  all  difficulties  arising  in  connection 

therewith. 

4.  The  situation  of  the  out-stations  shall  be  as  shown  on  the  plan 
and  where  practicable  shall  be  established  in  connection  with  the 
Cottage  Hospitals.  They  will  be  opened  in  the  order  decided  by  the 
amount  of  work  likely  to  be  done  at  each  and  will  be  arranged  to 
meet  the  circumstances  of  each  particular  area,  being  larger  and  more 
completely  equipped  in  the  denser  localities  than  in  the  more  scattered 
areas. 

5.  The  out-stations  will  be  provided  and  equipped  by  the 
County  Council. 

6.  The  uses  of  the  out-stations  are  primarily  for  examination 
and  out-patient  treatment  in  connection  with — 

a.  Venereal  Diseases, 

b.  Tuberculosis, 

c.  Ex-service  Men, 

d.  School  Children, 

e.  Maternity  and  Child  Welfare, 

for  which  provision  has  been  made  at  the  public  expense.  They 
will  also  be  available  for  other  conditions  for  which  provision 
may  be  made  in  the  future,  and  may  be  used  by  the  Medical  Officers 
for  insured  persons  and  general  hospital  cases,  by  arrangements 
with  the  County  Council. 

7.  The  Staff  will  be — 

a.  Medical 

(1)  A  regular  staff  consisting  of  local  practitioners 
appointed  as  medical  officers  by  the  Board  of  Repre¬ 
sentatives. 

(2)  A  consultant  staff  consisting  of — 

(a)  Visiting  Staff  of  the  General  Hospital. 

(b)  The  Tuberculosis  and  Venereal  Disease 

Officer  of  the  County  Council. 

b.  Nursing 

(1)  District  Nurse 

J*  Report  of  County  Medical  Officer  on  Health  to  Gloucestershire  County 

Council,  June  4,  1919. 


44 


(2)  Masseur  and  Masseuse  ) 

(3)  V.  D.  Orderly  and  Nurse  (  peripatetic 

8.  The  Out-stations  will  be  opened — 

a.  Weekly  at  a  convenient  hour,  on  a  fixed  day,  for  atten¬ 
dance  by  the  medical  officer,  or  oftener  if  necessary  for 
the  work  of  the  County  Council. 

b.  Periodically,  for  attention  by  members  of  the  Visiting 
Staff,  and  by  the  Tuberculosis  and  Venereal  Disease  Officer, 
by  arrangement. 

c.  As  often  as  may  be  necessary  for  intermediate  treat¬ 
ment  by  the  Nursing  Staff. 

d.  At  such  other  times  for  the  convenience  of  the 
Medical  Officer  in  seeing  his  own  patients  and  hospital  cases, 
by  arrangement  with  the  County  Council. 

9.  A  register  shall  be  kept  of  all  attendance  in  a  book  provided 
for  the  purpose,  and  a  case  file  kept  for  each  case  containing  such 
simple  notes  as  may  be  necessary  for  the  medical  history  of  the 
patient. 

It  should  be  pointed  out  that  such  proposals  as  these  do  not 
involve  the  idea  of  a  universally  state-employed  medical  service. 
Your  investigators  believe  that  the  idea  of  such  a  service  is  repug¬ 
nant  to  the  great  majority  of  physicians  and  patients,  and  that  the 
best  results,  at  least  for  some  time  to  come,  are  obtainable  in  other 
ways.  For  example,  the  general  practitioner  who  is  to  be  available 
to  give  public  medical  service  to  any  comer,  would  (as  now)  go  upon 
the  Government’s  list  and  have  assigned  to  his  care  those  families 
who  elected  to  have  him  as  their  physician.  He  would  then  be  paid 
on  a  capitation  basis.  If  any  individual  feels  that  he  would  get 
better  service  by  going  to  a  doctor  who  is  not  on  the  public  list, 
or  by  paying  a  public  practitioner  in  his  other  capacity  as  a  private 
doctor  for  the  service  he  gets,  he  is  at  liberty  to  elect  either  of 
these  alternatives.  And  the  doctor  meanwhile  has  whatever  spur 
is  provided  both  by  the  opportunity  of  getting  on  in  the  public 
service  or  of  making  good  in  private  practice. 

In  short,  there  would  be  necessary  the  employment  on  full 
or  part  time  (as  at  present  with  the  insurance  doctors)  by  the 
public  health  authorities  of  a  constantly  increasing  number  of 
general  practitioners  and  specialists,  thus  accelerating  an  exist¬ 
ent  tendency.  But  there  would  still  be  the  widest  possible  lati¬ 
tude  for  those  persons  who  chose  to  secure  their  own  medical 
and  institutional  care,  and  for  those  doctors  who  preferred  on 
whole  or  part  time,  to  carry  on  private  practice. 

Moreover,  the  existence  side  by  side  of  a  considerable  amount 
of  both  public  and  private  practice  would  undoubtedly  react  whole¬ 
somely  on  each,  keeping  initiative,  energy,  professional  ambition  and 
a  spirit  of  public  service  alive  and  growing. 


45 


In  short,  the  medical  benefits  under  an  act  should  be  as 
liberal  as  possible,  including  the  maximum  of  institutional  pro¬ 
visions  as  well  as  general  practitioners'  care,  and  all  treatment 
should  be  carefully  co-ordinated  to  bring  into  effective  use  for 
the  insured  and  his  dependents  all  local  and  all  state  facilities. 

C.  Having  made  medical  provision  available  for  all  insured  and 
their  dependents,  it  would  still  be  necessary  to  make  provision  on  a 
compulsory  insurance  basis  for  payment  of  cash  benefits  to  workers 
when  they  are  unable  to  work  and  secure  wages. 

All  employed  persons  should  be  required  to  insure  in  a  state 
fund  out  of  which  cash  benefits  would  be  paid  during  incapacity 
due  to  illness. 

D.  Cash  benefits  should  be  at  least  50  per  cent  of  wages. 

E.  The  administration  of  cash  benefits  should  be  decentralized 
on  the  disbursement  side  on  a  geographical  basis,  but  centralized  on 
the  collection  side,  so  that  the  Fund  would  be  pooled  and  the  risk 
distributed  over  an  entire  state.  Benefits  should  be  paid  through  a 
local  agency,  which  would  be  in  the  control  of  representatives  of  the 
affected  groups. 

F.  The  cash  maternity  benefit  should  not  be  administered  on 
an  insurance  basis,  but  should  be  universally  available  and  should  be 
of  an  amount  to  cover  fully  the  expenses  of  confinement.  There  is 
much  to  be  said  for  a  policy  which  makes  of  this  benefit  a  maternity 
endowment  of  an  even  more  substantial  amount. 

Medical  service  should  be  freely  available  for  all  maternity  cases. 

O 

It  is  recognized  that  these  conclusions  may  seem  to  your  Com¬ 
mission  to  extend  into  a  larger  field  than  that  of  the  immediate 
inquiry.  They  are,  however,  the  conclusions  to  which  your  investi¬ 
gators  were  led  in  an  honest  and  wholly  unprejudiced  effort  to 
discover  the  good  and  the  bad  in  the  English  act,  from  the  point  of 
view  of  its  furtherance  of  the  public  health  and  from  the  point  of 
view  of  its  availability  for  American  uses. 

It  may,  of  course,  be  necessary  for  each  separate  community 
to  make  the  same  social  experiments  and  learn  by  the  same 
mistakes.  It  is  to  be  hoped,  however,  that  this  is  not  true ;  that 
it  is  possible  for  one  community  to  build  upon  the  experience  of 
another.  And  the  experience  proves,  as  your  investigators  read 
the  evidence,  that  the  acute  necessity  for  greatly  developing  the 
public  medical  facilities  of  the  state  should  be  recognized,  and 
set  apart  from  and  in  addition  to  any  insurance  provisions.  The 
two  are  not  mutually  exclusive.  They  are  supplementary.  But 


46 


the  proper  and  wise  development  of  the  public  health  services  will 
and  should  modify  the  kind  of  insurance  plan  which  is  adopted. 

Your  investigators  recognize  fully  the  painful  fact  that  those 
forces  which  have  for  various  reasons  been  in  opposition  to  the 
introduction  of  health  insurance  into  America,  have  taken  the 
line  that  “  prevention  ”  rather  than  insurance  is  the  method  to 
pursue.  Where  this  position  was  simply  taken  to  delay  matters 
and  “  preventive  ”  was  simply  a  plausible  cant  phrase  with 
which  to  oppose  any  governmental  action,  the  opposition  has  of 
course  been  sinister  to  a  degree. 

But  this  fact  should,  nevertheless,  not  be  allowed  to  lead  to  a 
slighting  of  the  immediate  value  and  need  of  aggressively  preventive 
work.  Hence,  if  we  are  to  meet  that  opposition  most  effectively 
we  might  well  take  up  the  slogan : 

Medical  and  institutional  service  freely  available  for 
all  employed  persons  and  for  their  families,  with  cash 
benefits  for  physically  incapacitated  workers  out  of  a 
fund  created  by  joint  contributions,  and  with  the 
strengthening  and  co-ordinating  of  the  federal,  state 
and  local  public  health  activities  on  behalf  of  children, 
mothers,  the  subnormal  and  abnormal,  the  aged  and 
those  suffering  from  all  infectious  diseases. 

It  is  not  a  question  of  prevention  or  insurance.  It  is — when  all 
elements  in  the  problem  are  faced  at  once — a  question  of  assuring 
simultaneously  adequate  medical  service,  prevention  and  cash  sub¬ 
vention.  And  there  is  no  good  reason  why  these  three  aspects  of 
a  public  program  should  not  be  developed  together.  Certainly  to 
allow  the  advocacy  of  one  to  be  used  as  a  basis  for  opposition  to 
another  is  unscientific  and  short-sighted. 

This  report  will  certainly  be  construed  wrongly  if  it  is  taken  to 
be  unfavorable  to  health  insurance  in  general  or  to  the  British  act  in 
particular.  It  aims  rather  to  give  a  discriminating  statement  of  the 
extent  to  which  insurance  has  been  able  to  carry  out  the  original 
promises  and  purposes  of  its  proponents. 

The  British  Health  Insurance  Act  has  been  a  distinctly  for¬ 
ward  step  in  social  legislation.  It  is,  however,  to  be  hoped  that 
your  Commission  will  see  its  way  clear  to  favoring  a  program 
at  once  more  thorough-going,  far-reaching,  economical  and 
scientific,  which  will,  however,  include  an  application  of  the 
insurance  idea  in  its  legitimate  sphere. 


47 


Appendix 


Persons  Interviewed  in  Course  of  Inquiry  into 
British  Health  Insurance 


Mr.  W.  A.  Appleton,  secretary,  General  Federation  of  Trades  Unions;  Mr.  John 
Baker,  secretary,  Iron  &  Steel  Trades  Confederation;  Mr.  Barlow,  assistant  secretary, 
Workers’  Union;  Dr.  Ethel  Bentham,  panel  doctor,  London,  Member  Labour  Party 
Committee  on  Public  Health;  Mr.  George  P.  Blizard,  insurance  expert  (former  secretary, 
Labour  Party  Committee  on  Public  Health) ;  Miss  Margaret  G.  Bondfxeld,  secretary. 
National  Federation  of  Women  Workers;  Mr.  G.  A.  Stuart-Bunning,  secretary,  National 
Federation  of  Sub-Post  Masters;  Mr.  G.  W.  Cantor,  insurance  executive  of  Union  of 
Post  Office  Workers;  Mr.  A.  S.  Cole,  Peek,  Frean  &  Co.,  Ltd.,  London;  Dr.  Alfred  Cox, 
secretary,  British  Medical  Association;  Mr.  Wm.  Cramp,  assistant  secretary,  National 
Union  of  Raihvaymen;  Mr.  G.  W.  P.  Epps,  Government  Actuary’s  Office;  Dr.  Letitia 
D.  Fairfield,  medical  officer  of  London  County  Council;  Sir  Walter  M.  Fletcher, 
secretary,  Medical  Research  Council;  Mr.  Thomas  Foster,  building  trades  employer, 
Bromley,  Lancashire;  Mr.  I.  G.  Gibbon,  administrative  official  in  Ministry  of  Health; 
Mr.  E.  Hackforth,  administrative  official  in  Ministry  of  Health;  Mr.  R.  W.  Harris, 
administrative  official  in  Ministry  of  Health;  Mr.  Frank  Hodges,  secretary.  Miners’ 
Federation  of  Great  Britain;  Mr.  D.  J.  Jenkins,  insurance  executive,  Iron  &  Steel  Work¬ 
ers,  Approved  Society;  secretary,  Association  of  Approved  Societies;  Miss  Eleanor  T. 
Kelly,  employment  manager,  Debenham  &  Co.;  Dr.  Wm.  Kerr,  medical  officer  of'  London 
County  Council;  Mr.  F.  Kershaw,  insurance  executive,  National  Federation  of  Women 
Workers;  Mr.  James  P.  Lewis,  executive  officer.  Hearts  of  Oak  Benefit  Society;  Mr.  E. 
J.  Lidbetter,  Bethnal  Green  Poor  Law  Union;  Mr.  Thomas  Lilly,  clerk,  Manchester 
Insurance  Committee;  Mr.  McFarlane,  divisional  inspector.  National  Health  Insurance, 
Manchester  District;  Sir  Charles  Macara,  cotton  manufacturer,  Manchester;  Mr.  A.  B. 
Maclachlan,  administrative  official  in  Ministry  of  Health;  Mr.  J.  S.  Middleton,  assistant 
secretary,  British  Labour  Party;  Mr.  Miller,  insurance  executive,  Workers’  Union; 
Miss  Murby,  inspecting  staff,  National  Health  Insurance;  Sir  Thomas  Neill,  president. 
National  Amalgamated  Approved  Society;  Dr.  Charles  A.  Parker,  consulting  physician; 
Dr.  Marian  Phillips,  women’s  organizer  of  Labour  Party;  Mr.  Charles  G.  Renold, 
firm  of  Hans  Renold  &  Co.,  Manchester;  Dr.  Harry  Roberts,  panel  doctor,  London;  Dr. 
Meredith  Roberts,  administrative  official  in  Ministry  of  Health;  Mr.  D.  A.  Rushton, 
editor,  National  Insurance  Gazette;  Mr.  Samuel  Sanderson,  secretary,  Insurance  Section, 
Amalgamated  Association  Card,  Blowing  and  Ring  Room  Operatives;  Mr.  Sharp,  Harrods’ 
Department  Store,  London;  Mr.  Robert  Smith,  insurance  executive,  Cooperative  Whole¬ 
sale  Society  Approved  Society;  Mr.  H.  O.  Stutchbury,  administrative  official  in  Ministry 
of  Health;  Mr.  Fred  Thomas,  Amalgamated  Weavers’  Association;  Mr.  John  Turner, 
secretary,  National  Amalgamated  Union  of  Shop  Assistants;  Miss  Ward,  inspecting  staff. 
National  Health  Insurance  Dept.;  Mr.  Warren,  insurance  executive,  National  Amalga¬ 
mated  Union  of  Shop  Assistants;  Sir  Alfred  W.  Watson,  government  actuary;  Mr.  & 
Mrs.  Sidney  Webb,  economists,  members  1909  Poor  Law  Commission;  Dr.  A.  Welpley, 
secretary,  Medico-Political  Union;  Dr.  J.  S.  Whitaker,  administrative  official  in  Ministry 
of  Health;  Mr.  H.  L.  Woolcombe,  secretary,  London  Charity  Organization  Society. 


